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Topical tranexamic acid reduces need for anterior nasal packing in epistaxis

Topical tranexamic acid for epistaxis reduces the need for anterior nasal packing, the time spend in ED and re-bleeding levels after 24 hours

Topical tranexamic acid used in the treatment of epistaxis in an emergency department (ED), reduces the need for anterior nasal packing, a lower rate of stay for more than 2 hours and incidence of re-bleeding 24 hours within 24 hours of admission according to a randomised trial by a team of Iranian researchers.

Epistaxis occurs in up to 60% of the worldwide population during their lifetime with approximately 6% of these individuals seeking medical attention. One form of treatment is anterior nasal packing and which is effective in as many as 85% of cases. However, whilst effective, anterior nasal packing is associated with complications including pain during introduction and removal of pack, bleeding after removal due to mucosal damage and synechia formation. While some data points towards a benefit from using topical tranexamic acid for epistaxis, others have found that there are no real benefits, particularly with respect to the time spent within an ED.

As a result, for the present study, the Iranian team undertook a randomised, double-blind trial to examine whether the use of topical tranexamic acid reduced the need for anterior nasal packing in patients with active, spontaneous, atraumatic anterior epistaxis presenting at an ED. All patients were initiated treated with an ice pack applied to the back of their neck and continuous irrigation of the mouth with cold water for 10 minutes. However, when these approaches failed, individuals were randomised to either cotton pledgets soaked with topical tranexamic acid, phenylephedrine and lidocaine (intervention group) or the same treatment but without tranexamic acid (the control group). Patients were discharged if they had no bleeding for 30 minutes and were found to be haemodynamically stable. The primary outcome was the use of anterior nasal packing at any time regardless of other treatments after the trial therapies. For the secondary outcome, the authors examined the need for an ED stay longer than 2 hours and re-bleeding within 24 hours of the ED admission, as well as re-bleeding within the subsequent 1 to 7 days.

Topical tranexamic acid and anterior nasal packing

A total of 240 patients with a mean age of 52.5 years (52.5% male) were randomised equally between the two groups.

The need for anterior nasal packing occurred in 50% of those using topical tranexamic acid compared to 64.2% of those in the control arm and this difference was statistically significant (odds ratio, OR = 0.56, 95% CI 0.33 – 0.94). Similarly, the intervention group were less likely to need to stay in the ED for more than 2 hours (OR = 0.38, 95% CI 0.18 – 0.82) or experience re-bleeding within 24 hours (OR = 0.41). However, there were no significant differences in the rate of re-bleeding 1 to 7 days after their admission to the ED.

The authors conclude that the use of topical tranexamic acid was a low cost, simple intervention for the control of bleeding in adults with spontaneous atraumatic anterior epistaxis.

Hosseinialhashemi M et al. Intranasal Topical Application of Tranexamic Acid in Atraumatic Anterior Epistaxis: A Double-Blind Randomized Clinical Trial Ann Emerg Med 2022

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