SGEM#321: The Times they are a Changin’ for TXA in Epistaxis?

Date: March 4th, 2021 Guest Skeptic: Dr. Anand Swaminathan is an Assistant Professor of Emergency Medicine at St. Joseph’s Regional Medical Center in Paterson, NJ. Managing editor of EM:RAP and Associate Editor at REBEL EM. Reference:  Reuben A et al. The Use of Tranexamic Acid to Reduce the Need for Nasal Packing in Epistaxis (NoPAC): Randomized Controlled Trial. Ann Emerg Med 2021 Case: A 70-year-old man presents with epistaxis. He’s got a history of atrial fibrillation and hypertension. His medications include apixaban, metoprolol and perindopril. He states that the nosebleed started that morning all of a sudden. Vitals are; a blood pressure 145/73 mmHg, heart rate 64 beats/minute, and oxygen saturation 99% on room air. You apply direct pressure for 10 minutes, but the bleeding continues. You administer phenylephrine topically, reapply pressure and, consider the use of tranexamic acid (TXA). Background: Epistaxis is a common Emergency Department (ED) complaint with over 450,000 visits per year and a lifetime incidence of 60% (Gifford 2008, Pallin 2005). The majority of refractory hemorrhages are seen in the elderly and in more than two-thirds of the time no cause for the epistaxis is identified. Standard anterior epistaxis treatment consists of holding pressure, use of local vasoconstrictors, topical application of silver nitrate and placement of an anterior nasal pack. The most common vasoconstrictor used in the US is oxymetazoline.  Emergency physicians have multiple tools in the toolbox to address this condition. We covered the topic of epistaxis on SGEM#53: Sunday Bloody Sunday. That episode we discussed 11 questions concerning epistaxis. It is a great review on the management of nosebleeds. The episode included the Dundee protocol for adult epistaxis management from 2012. I searched and could not find an updated version. ED patients with epistaxis often fail conservative management and end up with anterior nasal packs which are uncomfortable. This is even more common in the group of patients who are taking antiplatelet agents or anticoagulants. In recent years, TXA has been added to many physicians’ armamentarium based on a few relatively small studies. We reviewed two  of these randomized control trials (RCTs) on the SGEM including the 2018 publication looking at using TXA in patients taking antiplatelet drugs. (SGEM#210). Some of these RCTs looking at TXA for epistaxis have also been reviewed on REBEL EM and other FOAMed sites. The results were encouraging. Topical TXA has minimal safety concerns and is relatively inexpensive. However, the studies did have a number of limitations including, being single centered, relatively small sample sizes and a lack of blinding. The SGEM structured critical review was skeptical of TXA for treating nosebleeds and had a conservative bottom line: Despite some limitations in this un-blinded trial, topical tranexamic acid appears to improve some patient important outcomes in patients who are taking antiplatelet medications who present with epistaxis. Clinical Question: Does the use of topical, intranasal TXA reduce the need for application of anterior nasal packing in ED patients with epistaxis who fail conservative management? Reference:  Reuben A et al. The Use of Tranexamic Acid to Reduce the Need for Nasal Packing in Epistaxis (NoPAC): Randomized Controlled Trial. Ann Emerg Med 2021 Population: Patients older than 18 years of age presenting with persistent epistaxis after local pressure and/or ice was applied to the bridge of the nose for at least 10 minutes. If bleeding persisted (continued presence of blood on the upper lip after wiping emanating from the nares) patients were treated with cotton wool dental roll soaked with a topical vasoconstrictor and inserted into the affected nostril for 10 minutes. If the bleeding persisted after the removal of the vasoconstrictor dental roll, they were enrolled in the trial.