SGEM#395: Too Much Blood from My Nose – Will TXA Help?

Date: March 3, 2023 Reference: Hosseinialhashemi et al. Intranasal Topical Application of Tranexamic Acid in Atraumatic Anterior Epistaxis: A Double-Blind Randomized Clinical Trial. Ann Emerg Med. 2022 Guest Skeptic: Dr. Dominique Trudel is a CCFP-EM resident in Ottawa, Ontario. Her interest is serving French minority communities delivering care at the Montfort Hospital in Ottawa. Case: Jim is a 50-year-old male who presents to the emergency department with anterior epistaxis. He reported it started last night in his bedroom where he used a space heater. He denies nose picking. He tried applying pressure, but it didn’t work. Vitals are stable and he is not on any anticoagulants. Background: We have covered the topic of epistaxis several times on the SGEM. The first episode was SGEM#53: Sunday Bloody Sunday. This trial looked at 216 adult patients with anterior epistaxis and randomized them to topical TXA (500mg in 5ml) compared to anterior nasal packing. The results were impressive for stopping bleeding in <10min, discharge <2hrs, rebleeding <24hrs, and patient satisfaction.  TXA is a synthetic derivative of lysine that inhibits fibrinolysis and thus stabilizes clots that are formed. It has been tried in several medical conditions and been reviewed on the SGEM. There is also a short YouTube video discussing the evidence for TXA. Trauma (CRASH-2): 1.5% absolute mortality benefit (SGEM#80) Isolated TBI (CRASH-3): No statistical difference in mortality (SGEM#270) Post-Partum Hemorrhage (WOMAN): No statistical difference in primary outcome (SGEM#214) Gastrointestinal Bleeding (HALT-It): No statistical difference in primary outcome (SGEM#301) Intracranial Hemorrhage (TICH-2 & ULTRA): No superiority for good neuro outcome (SGEM#236 and SGEM#322) That first SGEM episode on using TXA for epistaxis showing favorable results also discussed eleven questions concerning epistaxis. It’s a good overview on the management of epistaxis. The episode included the Dundee protocol for adult epistaxis management from 2012. A second RCT from the same group looked at TXA for adults with anterior epistaxis who were also taking antiplatelet medications. This too showed impressive results claiming superiority of TXA(SGEM#210). When the NoPAC trial was published, it curbed some of the enthusiasm for TXA in epistaxis (SGEM#321). It was the largest double-blinded RCT (N=496), and found no reduction in the need for anterior packing with the use of intranasal TXA. However, this trial included patients who had already failed 10 min of pressure and 10 min of packing with a topical vasoconstrictor. They also used a lower dose of TXA in the noPAC study. Another issue was that 65% of the patients were taking anticoagulants. Lastly, the primary outcome was different than the previous two RCTs claiming efficacy. These conflicting results have led to uncertainty regarding the use of TXA in patients with epistaxis. Hosseinialhashemi et al sought to provide some clarity with their trial looking at TXA in uncomplicated anterior epistaxis. Clinical Question: Should we use TXA for uncomplicated anterior epistaxis? Reference: Hosseinialhashemi et al. Intranasal Topical Application of Tranexamic Acid in Atraumatic Anterior Epistaxis: A Double-Blind Randomized Clinical Trial. Ann Emerg Med. 2022 Population: 18-year-old and older, stable patients with atraumatic anterior epistaxis, without bleeding disorders or anticoagulation. Excluded: Posterior bleeds, hemodynamically unstable, allergic to TXA; known nasopharyngeal, nasal cavity, or paranasal malignancy; pregnancy; the experience of out-of-hospital nasal packing; and epistaxis caused by trauma, known bleeding disorders, recent use of anticoagulation drugs or clopidogrel and patients who were prisoners. Intervention: Cotton pledgets soaked in TXA 500mg, phenylephrine 0.05g and lidocaine 10% x five sprays.