Nasal Packing vs TXA for Anterior Nose Bleeds

The Article: A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial

American Journal of Emergency Medicine 31 (2013) 1389-1392

The Idea: To determine if using a topical form of TXA is more efficacious than nasal packing in stopping anterior epistaxis

The Study:

1. Single center, randomized control trial of 216 patients

2. Inclusion criteria: idiopathic anterior epistaxis

3. Exclusion criteria: trauma, posterior epistaxis, known bleeding disorder, INR > 1.5, shock, visible bleeding vessel

4. PGY3 residents received 2-hr workshop in order to standardize nasal packing method

5. TXA group: cotton pledget soaked in injectable form of TXA (5ml of 100mg/ml) for 10min and placed in nasal cavity; bleeding was assessed q5min

6. Nasal packing group: cotton pledget soaked in lidocaine and epinephrine and placed in nasal cavity for 10min to shrink nasal mucosa; then cotton pledgets coated in tetracycline were packed; packing was removed in 3 days

Outcomes:

1. Bleeding stop time

2. Discharge from ED time

3. Re-bleeding in the first 24h and in 1wk

4. Patient satisfaction score on scale of 0 to 10

5. Complications in the ED

The Findings:

1. Decreased bleeding time in TXA group: 71% of TXA patents vs 31.2% of nasal packing patients had bleeding stop time of < 10 min

2. Decreased time to discharge in TXA group: 95.3% of TXA patients vs 6.4% of nasal packing patients were discharged from the ED in < 2 hrs

3. Decreased rate of re-bleeding in TXA group at 24h and 1wk: 4.7% vs 12.8%, and 2.8% vs 11%

4. Patient satisfaction score was greater in the TXA group: 8.5 vs 4.4

5. No difference in complication rate (i.e. nausea/vomiting)

Limitations:

1. Residents and patients not blinded

2. Nasal packing method not disclosed, and is not standardized across other hospitals

3. No information on severity of bleeding

4. TXA not readily available everywhere

5. Small study – 216 patients

6. No cost analysis

The Takeaway:

TXA is more efficacious and convenient than nasal packing in treating idiopathic anterior epistaxis. Treatment with TXA liberates patients from being discharged with uncomfortable nasal packing, taking antibiotics, and a return trip to have the packing removed. Patients are more satisfied with shorter ER visits, as are physicians with increased throughput, without an increased risk in re-bleeding or complications.

#HEENT #procedures