The patient was turning all shades of pale on his way to reverse Trendelenburg. From seashell, to ivory, to baby powder, to ghost. Our interaction had started innocently enough. Mr. E. said he had taken a few Motrin on top of his daily baby aspirin for a tight back. It began a bit later, he recounted, when he bent over to tie his shoe.
When I (Dr. Ballard) first laid eyes on him, I saw a gentle crimson rivulet meandering from the left nare into his whiskers, like a mustachioed Eleven from Stranger Things. The patient was attempting compression, pinching his nose rather than his vasculature. A blue foam clip was perched precariously on the tip of his nasal bridge, securely compressing superficial skin and tissues. “Ah, a quick fix,” I thought while aerosolizing Afrin and lido into his nasopharynx.
Before I could leave the room, however, the initial treatment triggered a staccato of coughing, and Mr. E.'s bleeding quickly turned from rivulet to river. I hastily inserted a Rhino Rocket and rotated the ENT chair backwards as Mr. E passed out. I hustled to find a nurse as a helpful hospitalist remarked, “Your patient in Room 12 is about to code.”
The following study is several years old, but has not yet widely diffused into practice (at least from our perspective). It looks at using an injectable form of tranexamic acid topically for epistaxis treatment. (Am J Emerg Med 2013;31:1389.) We have never met an emergency physician who relishes treating epistaxis or a patient who likes nasal packing, so it seems like a study that should grab our interest. Of course, sending a patient home with packing is generally accepted as safe from a clinical perspective and usually avoids bounceback bleeding.
But from a patient perspective (speaking from personal experience after I [DB] received a stiff elbow to my nose playing basketball), packing is miserable. Packing makes it nearly impossible to breathe, sleep, smell, and speak (at least in a tone that is tolerable to those nearby.) Ideal epistaxis management should involve sending patients home without packing. Any technique that allows for this is superior to the wide array of nasal packing options.
The Zahed study compared a tranexamic acid (TXA) cohort with a “usual care” nasal packing group of ED patients with anterior nosebleed. Eligible patients were randomized to receive a 15-cm cotton pledget soaked in the injectable form of TXA (500 mg in 5 mL) that was left in place until bleeding arrested or cotton soaked with epinephrine (1:100,000) + lidocaine (2%) for 10 minutes, and then packing with several cotton pledgets covered with tetracycline. Nasal packing, when done, was removed after three days, and rescue cautery was permitted for both groups. The primary outcomes were time to arrest bleeding, ED length of stay, rebleeding at one week, and patient satisfaction on a visual analog scale (VAS) at time of discharge.
The 216 enrolled patients were similar in age, platelet count, and INR, though the TXA group had a much higher rate of prior bleeding (58.1% vs. 13.6%). The TXA group (n=107) had significantly faster time to ED discharge (95.3% within two hours versus 6.4%) and lower rates of rebleeding at 24 hours (4.7% vs. 12.8%) as well as in the 24 hours to one-week time frame (2.8% vs. 11%). The self-reported satisfaction rate was also higher with TXA (VAS 8.5 ± 1.7) compared with anterior nasal packing (VAS 4.4 ± 1.8). Neither group had any serious adverse events.
The manuscript is rather thin on certain details (it is not clear if rescue cautery was used), and the comparison group received cotton pledgets only (rather than an inflatable/expandable packing). The same research group recently replicated its findings in a population at higher risk for rebleeding (patients on aspirin or clopidogrel), and the cumulative results are compelling enough to justify a trial in day-to-day practice.
Fortunately, Mr. E. in room 12 did not code, but he did require immediate resuscitation and soon became Mr. E. in Trauma A. His ghost-like doppelganger was replaced with a more perfused version of himself, so I initiated the TXA protocol. I removed the Rhino, and the pharmacist delivered the vial of injectable TXA to the bedside. I dripped it onto the cotton pledget and placed it in his nostril for 10 minutes: no bleeding, no repeat syncope. Mr. E. went home with routine nosebleed home care education and instructions to take an NSAID holiday. He did not return.
So far, so good using the TXA approach to epistaxis. Between us, we have had several additional successes and one warfarin-epistaxis ED failure that required the patient discharge home with packing. The most difficult aspect of the approach (at least in our EDs) is coordinating with the pharmacy to attain the injectable TXA, but otherwise there is little downside to adding TXA to your nosebleed armamentarium. If I ever get cracked in the honker again and need epistaxis care, I'll be asking for TXA.