The study also does not apply to posterior bleeds; patients with a preexisting bleeding disorder, major trauma, or an international normalized ratio >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 severity of bleeds.
Explore This IssueACEP Now: Vol 33 – No 10 – October 2014
While the results were impressive, it was only one RCT. The literature is full of examples of subsequent trials and systematic reviews invalidating a single RCT. Only time will tell if the results are valid, but it is the best evidence to date.
The Bottom Line
For anterior epistaxis, consider soaking the packing in TXA to stop the bleeding and get patients home sooner.
The 68-year-old man is informed that the traditional method involves packing his nose for three days with a follow-up to remove the packing. The alternative is to try packing with another solution, which has been shown in one study to stop the bleeding earlier, get patients out of the ED faster, have no difference in side effects, lead to less rebleeding, and have greater patient satisfaction. He chooses wisely and goes with the TXA packing, leaves after one hour, and does not bounce back to the ED within a week.
Thank you to Erich Hanel, MSc, MB, BCh, BAO, CCFP(EM), Best Evidence in Emergency Medicine faculty member, for his help on this review.
Remember to be skeptical of anything you learn, even if you learned it from The Skeptics Guide to Emergency Medicine.
Dr. Milne is chief of emergency medicine and chief of staff at South Huron Hospital, Ontario, Canada. He is on the Best Evidence in Emergency Medicine faculty and is creator of the knowledge translation project the Skeptics Guide to Emergency Medicine (www.TheSGEM.com).
Additional Resources on Epistaxis
- Skeptics Guide to Emergency Medicine. Episode 53: Sunday, Bloody Sunday. Available at: http://thesgem.com/2013/11/sgem53-sunday-bloody-sunday-epistaxis-and-tranexamic-acid/.
- Barnes ML, Spielmann PM, White PS. Epistaxis: a contemporary evidence based approach. Otolaryngol Clin North Am. 2012;45:1005-1017.
- 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, Toma A. Prospective study of the risk of not using prophylactic antibiotics in nasal packing for epistaxis.J Laryngol Otol. 2012;126:257-259.
- 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;114:38-40.
- Holbrook A, Schulman S, Witt DM, et al. Evidence-based management of anticoagulant therapy: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(2 Suppl):e152S-84S.