TXA vs Packing for Epistaxis

Written by Sam Parnell

Spoon Feed
Intranasal tranexamic acid (TXA) with nasal compression was as effective as Merocel nasal packing for bleeding cessation in anterior epistaxis, had a lower rebleeding rate, and was better tolerated than nasal packing.

Why does this matter?
TXA is an antifibrinolytic agent used to improve hemostasis and decrease bleeding. Several studies have demonstrated the utility of TXA for management of anterior epistaxis, usually by soaking nasal packing materials in TXA before insertion. However, since nasal packing has several disadvantages, could topical intranasal TXA be used in lieu of nasal packing for anterior epistaxis management?

Can TXA help stop the bleeding? Only the nose knows…
This was a single center, 135-patient randomized controlled trial that compared the effectiveness of external nasal compression after application of topical intranasal TXA, external nasal compression after application of topical intranasal saline (placebo-controlled group), and Merocel anterior nasal packing for stopping spontaneous anterior epistaxis with a secondary outcome of rebleeding within 24 hours. TXA was administered as atomized 500 mg diluted in 5 mL normal saline solution sprayed into both nostrils.

The success rate for stopping anterior epistaxis within 15 minutes was 91.1% (41 of 45 patients) in the nasal compression with TXA group, 93.3% (42 of 45 patients) in the nasal packing group, and 71.1% (32 of 45 patients) in the nasal compression with normal saline group. There was no statistically significant difference between the tranexamic acid and nasal packing groups.

Rebleeding within 24 hours occurred in 13.3% of patients in the TXA group, 26.7% in the nasal packing group, and 40% in the compression with saline solution group. Furthermore, 7 out of 45 patients in the nasal packing group had severe pain during nasal packing and requested the procedure be terminated. None of the patients in the TXA group complained of severe pain.

This study had several limitations and importantly only one nasal packing material (Merocel) was used for comparison. However, this study suggests that TXA application with nasal compression was as good as standard nasal packing at stopping bleeding, better at preventing rebleeding within 24 hours, and may be more comfortable and cost-effective than ready-made commercial anterior nasal packing.

Source
Evaluating Effectiveness of Nasal Compression With Tranexamic Acid Compared With Simple Nasal Compression and Merocel Packing: A Randomized Controlled Trial. Ann Emerg Med. 2019 May 9. pii: S0196-0644(19)30249-5. doi: 10.1016/j.annemergmed.2019.03.030. [Epub ahead of print]

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