SGEM#53: Sunday, Bloody Sunday (Epistaxis and Tranexamic Acid)

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Date: November 17, 2013

Guest Skeptic: Dr. Erich Hanel, Assistant Professor of Emergency Medicine at McMaster University and the newest member of the BEEM Dream Team

Case: A 72-year-old man presents with epistaxis. He has no history of coagulopathy but does have a history of hypertension, coronary artery disease and osteoarthritis. His vital signs are BP 154/92, HR 70 and RR 14. He is taking an ACE-I, hydrochlorothiazide 25mg and ASA 81mg.

Question: Is topical tranexamic acid (TXA) better than nasal packing for an anterior epistaxis?

Eleven Questions Concerning Epistaxis:

1. What is the incidence of epistaxis?

60% of the population will experience a nose bleed
Bimodal distribution (<10yrs and > 60yrs)
Majority of admissions for refractory hemorrhage in elderly 60-70 years
In the US 2005 there were 7 deaths related to epistaxis (all over 75 years)
70-80% no cause is identified

2. What are the common causes of epistaxis?

Anterior (Kiesselbach’s Plexus)
Remember there are anterior and posterior bleeds and there is post-nasal bleeding from a brisk or uncontrolled anterior bleed. This still has implications for aspiration and post-epistaxis melena and gastritis/vomiting. It will also affect your blood urea nitrogen levels if there is a chronic or recurrent component, if you decide to draw lab investigations.

3. Does hypertension cause epistaxis?

Debated
Often patients with epistaxis have elevated blood pressure but white coat is up to 20%
Atherosclerosis of Kesselbach’s predisposes you to bleeding, so this might contribute in the elderly distribution of patients
Might be useful to control long term blood pressure to prevent recurrent epistaxis in adults but not in the acute management in the ER. This may have some implication in who follows up epistaxis form the ED. In adults there may be benefit in family doctor follow-up to also re-examine blood pressure in terms of a preventative health exam.

4. How do you diagnose anterior versus posterior epistaxis?

You should be able to visualize 80% of anterior epistaxis
Use nasal thudicum or speculum. Personal protective gear. Headlamp if you have it.
Auroscope with light is fine. Sit the patient up in a proper chair. Blow out the clots.
Consider normal saline irrigation to clear clots. Rinse mouth out and spit to clear out oropharynx to look for fresh blood.
Consider signs and symptoms of hemorrhagic shock especially in the vulnerable like the common bimodal presentation patients (youth – congenital abnormalities, polyps, and the elderly with co-morbidities and anti platelet and anti coagulants)!
Seeing an anterior vessel bleeding is like chart code for “it’s not a posterior bleed”.

5. Do you need to do coagulation studies on epistaxis?

Not unless already taking anti-coagulants or a refractory paediatric hemorrhage requiring admission (Choose Wisely)
Reverse to therapeutic level, avoid reversing to sub therapeutic level. The risk of thromboembolism is higher than life threatening hemorrhage from epistaxis. Small dose of oral vitamin K (1mg) may be enough.

6. Do you need to reverse coumadin with epistaxis?

Just as you normally would
American College of Chest Physicians, recently discussed on Emergency Medicine Cases recommended for bleeding and INR > 10 to give 1-2 mg PO vitamin K and holding warfarin.

7. Do you need to do anything different for epistaxis for patients on NOAC?

Very debated in the literature
No antidotes
What are they: Dabigitran (Pradax, direct thrombin IIa inhibitor), Rivaroxaban (Xarelto) and Apixaben (Eliquis) are both factor Xa inhibitors
Remember that they have short half lives (12 hours), missed 2-3 doses treat as un-coagulated patient

8. How do you manage epistaxis in general (Dundee Protocol)?

Direct therapy, tamponade, vascular intervention
Topical vasoconstrictor preparations recommended include 1:1000 adrenalin (epinephrine),9 0.5% phenylephrine hydrochloride,10 4% cocaine, or 0.05% oxymeta- zoline solution,7 but few comparisons have been conducted. One study suggested that oxymetazoline may be more effective than 1:100,000 (dilute) adrenalin, and equally effective with less propensity to induce hypertension when compared with 4% cocaine (not available in many ED’s in Canada currently, concerns with elderly and coronary artery disease). Frazier suction catheter is the smaller tip catheter.
Note, ice in the mouth reduces anterior plexus blood flow by up to 20%

9. Are there any differences in the effectiveness of the different packing options?

Consider bilateral packing even for single side blood for extra pressure.
Ribbon gauze from posterior to anterior coated in petroleum jelly or antibiotic ointment.

10. Should you use antibiotics in epistaxis?

Feared complications: (keener kontest)
Staphylococcus aureus or Streptococcus progenies but this only occurred in postoperative patients
If concurrent infection; use antibiotics if appropriate
Antibiotic choices include; topical, clavulin, macrolide for penicillin allergic
5 days for prophylaxis is appropriate
All posterior packing (which are used in conjunction with anterior packing)
Consider for anterior packs in more than 24 hours for sure more than 72 hours
Some advocate topical antibiotic for 7 days after spontaneous epistaxis

11. How long should I leave anterior packs in?

No strong literature
1-3 days is common but up to 5-7 have been reported in surgical cases

Reference: Zahed R et al. A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial. Am J Emerg Med. 2013 Sep;31(9):1389-92.

Population: Adult ED patients (n=216)
Intervention: 15cm cotton packing soaked in tranexamic acid (500mg in 5ml), removed after bleeding stopped
Control: Cotton packing soaked in epinephrine (1:100,000) + lidocaine (2%) for 10 minutes and then re-packed with cotton pledgets covered with tetracycline
Outcome:Time to stop bleeding, length of stay (LOS), re-bleeding at 24hrs and 1 week and patient satisfaction

Result:

Authors’ Conclusion: “Topical application of injectable form of tranexamic acid was better than anterior nasal packing in the initial treatment of idiopathic anterior epistaxis.”

BEEM Comments: This was a good randomized clinical trial (RCT) looking at another way to treat a common problem in the emergency department. There was one significant imbalance in the two groups with more people in the TXA group having a history of epistaxis (58% vs 14%). This could exaggerate the effectiveness of the intervention. The study also does not apply to posterior bleeds, patients with a pre-existing bleeding disorder, major trauma, INR>1.5 and when a bleeding vessel is visible. There was no blinding for the providers and patients which could have introduced some bias. Also, there was no grading of epistaxis so we do not know if topical TXA is better or worse than packing for varying severities of bleeds. The results were impressive but it was only one RCT. There are many examples of subsequent superior trials and systematic reviews showing single RCT results to be invalid. While it appears to be the best evidence to date, only time will tell if the results are valid.

BEEM Bottom Line: For anterior epistaxis consider soaking the packing in TXA to stop the bleeding and get them home sooner.

Case Resolution: The 72-year-old man is informed the traditional method involves packing his nose for three days with a follow-up to remove. The alternative is to try packing with another solution which has been shown in one study to stop the bleeding earlier, get you out of the emergency department faster, no difference in side effects, less re-bleeding and has greater patient satisfaction. He chose wisely and when with the TXA packing, left after one hour and did not bounce back to the emergency department within a week.

Additional Papers on Epistaxis:

Barnes ML, Spielmann PM and White PS. Epistaxis: A Contemporary Evidence Based Approach. Otolaryngol Clin North Am. 2012 Oct;45(5):1005-17
Biggs TC, Nightingale K, Patel NN, Salib RJ. Should prophylactic antibiotics be used routinely in epistaxis patients with nasal packs? Ann R Coll Surg Engl 2013; 95: 40–42
Pepper C, Lo S and Toma A. Prospective study of the risk of not using prophylactic antibiotics in nasal packing for epistaxis. J Laryngol Otol. 2012 Mar;126(3):257-9
Thaha MA, Nilssen EL, Holland S, et al. Routine coagulation screening in the management of emergency admission for epistaxis—is it necessary? J Laryngol Otol. 2000 Jan;114(1):38-40
Teymoortash A, Sesterhenn A, Kress R, et al. Efficacy of ice packs in the management of epistaxis. Clin Otolaryngol Allied Sci. 2003 Dec;28(6):545-7

KEENER KONTEST: There was no winner last week:( Listen to this weeks podcast for the Keener question. If you know the answer then send your answer to TheSGEM@gmail.com with keener kontest in the subject line. Be the first one with the correct answer and I will send you a cool SGEM skeptical prize.

There is a great new FOAMed resource that I wanted to mention. It fits with the theme of this not being a rebel podcast, this is Sunday, Bloody Sunday. But there is a new REBEL in Emergency Medicine. It is a project by Dr. Salim Rezaie, Clinical Assistant Professor, Emergency Medicine & Internal Medicine at the University of Texas. REBEL stands for Rezaie’s Evidence Based Evaluation of Literature in Emergency Medicine/Internal Medicine. Salim has got some great content and I suggest you check it out.