Effective topical tranexamic acid for epistaxis

Topical tranexamic acid is effective for epistaxis, reducing the need for anterior nasal packing and bleeding levels after 24 hours

Use of topical tranexamic acid in an emergency department (ED) for the treatment of epistaxis reduces the need for anterior nasal packing, the rate of stay in the ED greater than 2 hours, and the incidence of new 24-hour bleeding within 24 hours of admission. These are the main conclusions of a randomized trial conducted by a team of Iranian researchers.

Epistaxis can affect up to 60% of the population during their lifetime and prompts around 6% of individuals to seek medical attention. One form of treatment for epistaxis is anterior nasal packing, which has been shown to be effective in 85% of cases. However, anterior nasal tamponade is associated with complications, including pain during insertion and removal of the tampon, bleeding after removal due to mucosal damage, and formation of synechiae. An alternative treatment is topical tranexamic acid while some data indicate a benefit from using topical tranexamic acid for epistaxis, others have found that there are no real benefits, particularly regarding time spent in an emergency department.

Given these disparities in the literature, for the present study, the Iranian team undertook a randomized, double-blind trial to examine whether the use of topical tranexamic acid reduced the need for anterior nasal packing in patients with epistaxis. active, spontaneous and atraumatic anterior presenting with a DE. All patients were treated with an ice pack applied to the back of the neck and continuous irrigation of the mouth with cold water for 10 minutes. However, when these approaches failed, individuals were randomized to receive either cotton pads soaked in topical tranexamic acid, phenylephedrine, and lidocaine (intervention group) or the same treatment but without tranexamic acid (control group ). All medications were pre-packaged and numbered so clinical staff and patients were unaware of their treatment allowance. If an individual had no bleeding for 30 minutes and was hemodynamically stable, they were discharged from the ward. The researchers defined the primary outcome as the use of an anterior nasal pack at all times, independent of other treatments after the trial therapies. Secondary outcomes included the need for an emergency department stay longer than 2 hours, new bleeding within 24 hours of admission to the emergency department, and new bleeding within 1 to 7 following 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 randomized equally between the two groups.

The need for anterior nasal packing occurred in 50% of those treated with topical tranexamic acid compared with 64.2% of those in the control group, a difference that was statistically significant (odds ratio, OR = 0.56, 95% CI 0.33 – 0.94). Similarly, the intervention group was less likely to need to stay in the emergency department for more than 2 hours (OR = 0.38, 95% CI 0.18, 0.82) or to have a new 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 emergency room.

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

Hosseinialhashemi M et al. Topical intranasal application of tranexamic acid in atraumatic anterior epistaxis: a randomized, double-blind clinical trial Ann Emerg Med 2022

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