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

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

Podcast Link: SGEM53
Date:  November 17, 2013
Title: Sunday, Bloody Sunday – Epistaxis and Tranexamic Acid

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

Case Scenario: 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

imagesENT_acute_nose_arteries2. 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.Screen Shot 2013-11-17 at 9.50.19 AM

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)?Screen Shot 2013-11-17 at 11.01.08 AM

  • 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?afp20050115p305-f2

  • 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:

Screen Shot 2013-11-17 at 11.13.25 AM

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

Hanel_Erich_webBEEM 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 72yo 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:

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.

Remember to be skeptical of anything you learn, even if you heard it on The Skeptics’ Guide to Emergency Medicine.

  • Salim R. Rezaie

    Hello Ken & The SGEM Community,
    First of all fantastic post. This is a common complaint, and you have done a beautiful job laying out an algorithm to follow as well as a review of the literature. Secondly, TY very much for the shoutout of the new web page. By no means is it at The SGEM status, but hopefully putting out some good quality info like you do here.

    Salim

    • TheSGem

      You are a REBEL up-loading some great content. Keep up the good work. Viva la #FOAMed

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  • ellrodt

    Hello, thanks for this nice piece of work.

    But what do you mean ‘Hypertension” among the causes of epistaxis ?

    I see it the other way round.

    Besides, anytime I see a paper on Hypertensive emergencies or urgencies, I never see epistaxis. But this is paper based medicine vs patient based medicine so , not a valid argument, I concede.

    I happened to hear ENT called for difficult cases ask me to lower the blood pressure, well , lower blood bressure with drugs in a bleeding patient with no proof of effectiveness …. ahem.

    • Erich

      Hypertension isn’t a cause of epistaxis and certainly isn’t a classic sign of end organ damage. It is a misconception out there and patients often present with symptoms they relate to elevated blood pressure and hypertension. Perhaps point three was not as clear as it should be. Thanks.

  • Ian Mitchell

    I really enjoyed the podcast, but I felt that I had to add a comment about cocaine. I was a little surprised to hear about your unfamiliarity with it, as it is the only topical vasoconstrictor that I remember using in my residency at McMaster, then 8 years at St Paul’s and now 6 years in Kamloops and I am still using it, though most are switching to xylometalozine. There is a general caution in using it in the elderly or hypertensives, but I have generally not noticed any cardiovascular complications.

    Patients don’t seem to get high from it and it contains some sort of colloidal ingredient that reduces the ability to divert the ingredients.

    See you at Ski-BEEM

    • TheSGem

      Ian:
      Thanks for this feedback. We had cocaine in the ED when I started working in 1997. It is not something I ever used because of the caution in the elderly. Now we no longer carry cocaine.
      Have you considered or tried TXA? Would be interested in hearing how it works for you.
      Cheers,
      Ken

      • Ian Mitchell

        We are starting to use TXA as a department, mostly as the liquid to inflate merocel pledgets after insertion. Interestingly after reading the article, I ended up tubing an intoxicated pt with nosebleed and gave iv txa, based on something I had read elsewhere in the article. Worked.

        • TheSGem

          that is great. Will you be coming to SkiBEEM?
          Ken

  • Matt Dawson

    Great post! I can’t wait to try this out.

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    • David:
      Looks like you found the SGEM episode on epistaxis useful. Thanks for spreading the FOAMed.
      Ken

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  • marie

    do we have any information about systemic effect of topical TXA?

    • TheSGem

      Thanks for the question. I will check with Erich Hanel and ask him to get back to you.
      Ken

    • Erich

      I have not seen any literature on systemic effects of localized topical TXA, especially intranasal. There are certainly papers and comments out there on systemic effects of parenteral TXA, so a lot of possible side effects could be inferred from oral/parenteral administration as a starting point at least. Recently there has been some debate on the outcomes for topical intranasal, see Emerg Med J. 2014 May;31(5):436-7. doi: 10.1136/emermed-2014-203763.3

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