Hot Off the Press: Topical Tranexamic Acid Compared With Anterior Nasal Packing for Treatment of Epistaxis in Patients Taking Antiplatelet Drugs

Epistaxis is a common presenting complaint in the emergency department (ED), with a variety of possible management options including pressure, vasoconstricting medications, cautery, and nasal packing.1, 2 The use of antiplatelet medications can make epistaxis more difficult to control.3 Tranexamic acid (TXA) is an antifibrinolytic agent useful in a wide variety of hemorrhagic conditions. A prior randomized control trial by the authors of this study demonstrated improved epistaxis control with topical TXA compared to anterior nasal packing.4 However, the literature is not consistent, and no prior study has focused on patients taking antiplatelet medications.5 This study aimed to compare topical TXA and anterior nasal packing in the management of anterior nasal epistaxis in patients on antiplatelet therapy. This is a nonblinded, randomized controlled trial comparing topical TXA and anterior nasal packing in the treatment of anterior epistaxis in patients on antiplatelet medications whose bleeding persisted despite 20 minutes of pressure. Patients were randomized to either TXA (a cotton pledget soaked with 500 mg of TXA and inserted into the affected nostril until hemostasis was achieved) or anterior nasal packing (pretreatment with a cotton pledget soaked in epinephrine and 2% lidocaine for 10 minutes followed by anterior nasal packing with tetracycline ointment left in situ for 3 days). Among the 124 patients included, bleeding at 10 minutes was better controlled in the TXA group (an absolute risk reduction of 44%; 95% confidence interval [CI] = 26%–57%; p < 0.001). The TXA group also had less recurrent bleeding in the first week, a shorter ED length of stay, and higher patient satisfaction. This is a well-conducted prospective, randomized control trial with a few minor threats to validity. The patients and treating clinicians were unblinded, which could bias the results. However, the outcome assessors were blinded. This trial is also as risk of selection bias, as although they tried to include consecutive patients, 92 of the 384 patients approached were excluded because of lack of consent. The choice to use bleeding at 10 minutes as the primary outcome may result in an unfair comparison, as traditional anterior packing requires time to allow a clot to stabilize. However, secondary outcomes looking at bleeding at 24 hours and 1 week also favored TXA, and earlier cessation of bleeding may be an important outcome for our patients. The authors report a shorter ED length of stay in the TXA group, but do not report the actual time spent in the ED in each group, so it is unclear if this difference was clinically significant. As there are many treatment options for epistaxis, potential confounders exist, and unfortunately the use of other treatment options such as cautery, vasoconstrictors, and commercial packing devices is not commented upon. Furthermore, the use of traditional anterior packing compared to the more widely used commercial packing devices may limit the applicability of the results. Finally, in this study anterior packing was primarily done by trainees (PGY2s and PGY3s), so it is possible that the results will not generalize to more experienced clinicians. There were 62 patients in the TXA group and 62 patients in the anterior nasal packing group. Hemostasis was achieved by 10 minutes in 73% of the TXA group and 29% of the anterior packing group (an absolute risk reduction of 44%; 95% CI = 26%–57%; p < 0.001). Recurrent nasal hemorrhage in the first week was reported in 5% of subjects who received TXA versus 21% who received anterior packing (p = 0.007). Discharge from the ED in <2 hours was accomplished in 97% of TXA group versus 21% anterior packing group (p < 0.001). Patients allocated to the TXA group reported higher levels of satisfaction compared to those allocated to anterior nasal packing. There was no significant difference in complications between the two treatment groups. This study supports the use of topical TXA in the management of anterior epistaxis in patients on antiplatelet therapy, as it results in earlier hemostasis, decreased recurrent bleeding at 1 week, and higher patient satisfaction. It is unclear how TXA would compare to commercial packing devices. It is also unclear exactly where TXA should fit into the epistaxis management algorithm. Although there was no difference in complications noted, and TXA seems quite safe in other contexts,6, 7 this trial is too small to make definitive conclusions about adverse events. Paper in a Pic infographic by Kristy Challen: @CHeitzMD: This has completely changed my practice. Get out the clot, Afrin and txa, pressure and I have a > 80% success rate #SGEMHOP. @TheSGEM: Changed my practice too. Using TXA regularly for epistaxis. @KristyChallen: It hasn't changed mine as I was already using TXA! 1st line if simple squeezing doesn't work. This randomized controlled trial demonstrated that topical TXA resulted in more rapid bleeding cessation, less risk of rebleeding, shorter ED length of stay, and higher patient satisfaction in patients taking antiplatelet medications. Topical TXA, without or without other therapies, is a reasonable management option for patients with epistaxis.

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