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Reference: Acad Emerg Med 2017 Nov 10 early online (level 2 [mid-level] evidence)
- Use of aspirin or clopidogrel is associated with an increased risk of epistaxis.
- A randomized trial with 124 adults with anterior epistaxis taking antiplatelet drugs compared the efficacy of tranexamic acid-soaked pledgets removed after bleeding cessation vs. 3-day usual anterior packing with epinephrine and lidocaine-soaked pledgets followed by tetracycline-impregnated pledgets.
- Bleeding was stopped within 10 minutes in 73% of patients with TXA pledgets vs. 29% with anterior packing (p < 0.001, NNT 3) and almost all patients who were treated with TXA pledgets were able to leave the emergency department within 2 hours (97% vs. 13% with anterior packing, p < 0.001, NNT 2). Also, a significantly lower rate of rebleeding within 1 week was observed in the TXA group (in 5% vs. 21% with anterior packing, p = 0.007, NNT 7).
Treatment with aspirin or clopidogrel is associated with an increased risk of epistaxis (Clin Otolaryngol 2009, Laryngoscope 2010) and can complicate its management. Initial management of epistaxis includes manual removal of large clots, application of topical vasoconstrictors (0.05% oxymetazoline or gelatin-thrombin hemostatic matrix sealant) and local anesthetic, and nasal pinching for 10-15 minutes with the patient leaning forward. For patients who continue to bleed despite initial management, decongestant-soaked pledgets may be applied on the affected side for 10 minutes followed by cauterization of any bleeding points if necessary. If bleeding persists, application of nasal packing for 24-48 hours may be considered in patients with anterior nasal epistaxis. Use of tranexamic (TXA)-soaked pledgets has been shown to control anterior epistaxis better than anterior nasal packing in patients without blood disorders (Am J Emerg Med 2013), but its efficacy in patients taking antiplatelet drugs has not been evaluated. A recent randomized trial investigated the efficacy of applying TXA-soaked cotton pledgets until bleeding cessation vs. 3-day usual anterior packing with epinephrine and lidocaine-soaked pledgets applied for 10 minutes followed by several tetracycline-impregnated pledgets applied for 3 days. All 124 patients presenting to the emergency department had persistent anterior epistaxis despite 20 minutes of compression of both nostrils and were taking aspirin, clopidogrel, or both.
Bleeding was stopped within 10 minutes in 73% of patients with TXA-soaked pledgets vs. 29% with anterior packing (p < 0.001, NNT 3). The median time to bleeding cessation was shorter in the TXA group (10 minutes vs. 15 minutes with anterior packing, p < 0.001) and almost all patients who were treated with TXA pledgets were able to leave the emergency department within 2 hours (97% vs. 13% with anterior packing, p < 0.001, NNT 2). Rates of rebleeding within 24 hours were not significantly different between groups (in 5% vs. 10%) while the rate of rebleeding within one week was significantly lower in the TXA pledget group (in 5% vs. 21% with anterior packing, p = 0.007, NNT 7). Patient satisfaction scores at time of discharge were significantly higher in the TXA pledget group (median score 9 points vs. 4 points on 10-point scale, P < 0.001). There was no significant difference in nausea, vomiting, or treatment intolerance (in 10% with TXA pledgets vs. 5% with nasal packing).
Compared to 3-day usual anterior packing, TXA-soaked pledgets applied until bleeding cessation shortened the time to bleeding cessation and decreased risk of rebleeding within 1 week in patients with anterior epistaxis who were taking antiplatelet drugs. Almost all patients managed with TXA pledgets could leave the emergency department within 2 hours and satisfaction with this treatment was greater compared to anterior packing. Although it was not possible to blind the patients or physicians to treatment, it should be noted that knowledge of the intervention may have affected assessment of the outcomes. Patients with epistaxis taking antiplatelet drugs may require more interventions and longer hospital stays than those not on therapy (Clin Otolaryngol 2012). Discontinuation of antiplatelet drugs does not provide short-term benefit because restoration of platelet function is dependent on platelet turnover. In cases of severe uncontrolled bleeding, platelet transfusions may be necessary. The findings from this trial indicate that application of TXA-soaked pledgets should be considered for conservative management of bleeding in patients with anterior epistaxis taking antiplatelet drugs.
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