In this episode, I’ll discuss whether the manner of tranexamic acid application changes the effectiveness for epistaxis.
Epistaxis in ED patients is first treated with topical measures (usually a vasoconstrictor), and if it is unsuccessful, treatment progresses to anterior packing. Anterior packing has risks including toxic shock syndrome and the inconvenience of needing another visit or appointment to remove the packing days later.
Topical application of tranexamic acid is hoped to reduce the need for anterior packing.
Back in episode 585 I discussed a randomized trial of almost 500 patients with spontaneous epistaxis that persisted after simple first aid and the application of a topical vasoconstrictor who were randomly allocated to receive topical tranexamic acid or placebo.
The tranexamic acid was applied by soaking a cotton gauze and leaving it in place at the site of bleeding for 10 minutes.
In that study, there was no difference in the need for packing between groups.
However, another double-blinded randomized controlled trial of tranexamic acid with a slightly different application method was just published in Annals of Emergency Medicine.
In this study, cotton pledgets soaked in either phenylephrine and lidocaine (control group) or tranexamic acid with phenylephrine and lidocaine (intervention group) were inserted into the patients’ nostrils for 15 minutes.
Tranexamic acid was associated with a lower rate of the primary outcome of the need for anterior nasal packing at 50.0% vs 64.2%.
In addition, tranexamic acid was associated with a lower rate of stay in the ED for more than 2 hours at 9.2% vs 20.8% and a lower rate of rebleeding in 24 hours at 15.0% versus 30% when compared with the rates in the control group.
Avoiding anterior nasal packing has a secondary benefit: Removing the packing requires a follow-up ED visit so if packing can be avoided not only is the time and expense of a procedure avoided but so is the follow-up ED visit.
In addition to leaving the tranexamic acid in for longer, the 2nd study involved applying the tranexamic acid as part of the initial treatment rather than waiting for the vasoconstrictor to fail like the 1st study did, suggesting that the manner of application changes the effectiveness of tranexamic acid.
Members of my Hospital Pharmacy Academy have access to practical training from a pharmacist’s point of view on epistaxis, tranexamic acid for different types of bleeding, along with over 200 practical trainings and other resources to help in your practice and to enhance your ability to precept students and residents. To get immediate access, go to pharmacyjoe.com/academy.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
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