Meta-analysis finds top options for nosebleeds were Merocel sponges, topical TXA, and the Rapid Rhino
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Figure: TXA, nasal packing, epistaxis, nosebleed, vasoconstrictor, epinephrine, lidocaine, tranexamic acid, oxymetazoline, Floseal, Surgiflo, Surgicel, Foley catheter, hemostasis, NoPac study, Rapid Rhino, Merocel, Rhino Rocket
FigureEpistaxis management can be challenging. Nosebleeds range in importance from trivial to lethal, and treatment options vary. Many bleeds resolve with a squirt of vasoconstrictor and direct pressure. If that doesn't work, at least it usually slows things down so a bleeding focus can be seen and cauterized.
Heavier bleeding might need more heroics. The historical standard has been to pack the anterior nose with gauze or a cotton pledget, usually after it's been soaked or smeared with the physician's favorite nosebleed seasoning, whether that's epinephrine, lidocaine, tranexamic acid (TXA), oxymetazoline, or a proprietary product such as Floseal or Surgiflo (a matrix goo of human thrombin and cow gelatin), or Surgicel, a similarly sticky cellulose polymer.
The packing itself can also get an upgrade. Rather than gauze or cotton pledget, one can use a proprietary product such as Merocel (a compressed sponge of hydroxylated polyvinyl acetate that expands and hardens when rehydrated), or Rhino Rocket, another expandable foam.
When packing alone isn't enough, we turn to an inflatable balloon, whether that's an improvisation involving a Foley catheter or a dedicated epistaxis-fighting device such as the Rapid Rhino. (Lots of alliterative “rhinos” make it confusing, but the marketing departments don't care; they know rhino means nose and sounds cool.)
Treatment Chaos
A research team from Taiwan has now stepped up to impose some welcome order on this treatment chaos. Their systematic review and network meta-analysis looked at 20 randomized controlled trials of 2994 patients and 12 different interventions. (Acad Emerg Med. 2023 Feb 9. doi: 10.1111/acem.14680; https://bit.ly/3mWuXt9.)
Seventeen of those 20 studies were based in emergency departments, making this highly relevant to our practice. (The other three were in ENT clinics.) Most of the studies were conducted in Iran or Turkey. (It's inspiring that I am learning to care for my American patients better by listening to Taiwanese colleagues summarizing what Turkish and Iranian physicians have field-tested.)
The primary outcome studied was immediate hemostasis within 30 minutes. The authors clearly understand that the nightmare of epistaxis, however, is not the initial bleeding but the rebleeding. Any moderately competent emergency physician can get epistaxis to stop long enough to run to the computer and hit “discharge patient;” the real trick is preventing the bleed from opening up again later that same day (or worse, that same shift). Secondary outcomes studied included two- and seven-day rebleeding events.
(Have you ever wondered how often the bleeding starts again when the ENT clinic deflates your balloon or yanks out your packing? Pretty often, it turns out.)
So, what did they find?
Immediate Hemostasis
Topical treatment with TXA significantly increased odds of immediate hemostasis. The odds ratio for success was 2.6 compared with a control treatment, which was defined as topical application of water, saline, lidocaine, or a vasoconstrictor followed by manual external compression, such as with a nose clip. TXA was even slightly more effective, with odds ratio of 2.76, compared with traditional nasal packing, which was defined as topical lidocaine or vasoconstrictor plus cotton pledgets or gauze covered with antibiotic ointment or petroleum jelly.
No other statistically significant differences were found in other head-to-head comparisons, but the authors calculated that the top three treatments for achieving immediate hemostasis were, in order, Merocel sponges, topical TXA, and the Rapid Rhino balloon gauze.
Of note, this meta-analysis included the NoPAC study, which randomized 496 epistaxis patients in United Kingdom emergency departments to TXA versus placebo, and asked if TXA prevented a need to progress to anterior nasal packing and found no benefit to it. (Ann Emerg Med. 2021;77[6]:631.) NoPAC has often been cited as our best quality data on TXA for epistaxis, but even with NoPAC's vote of no confidence included, the meta-analysis still finds a favorable effect from TXA.
What other statistically significant results did the meta-analysis show? Spoiler alert: It's all about TXA and the Rapid Rhino.
Topical treatment with TXA significantly reduced odds of two-day rebleeding compared with control treatments (OR 0.36) and traditional nasal packing (OR 0.45). The Rapid Rhino showed even lower rates of two-day rebleeding compared with control (OR 0.08) or traditional packing (OR 0.1). The authors calculated that the three best treatment options to prevent two-day rebleeding events were the Rapid Rhino, topical TXA used with traditional nasal packing, or topical TXA all by itself. Topical treatment with TXA even reduced odds of seven-day rebleeding compared with traditional nasal packing (OR 0.33).
The authors noted that nasal packing usually needs to be removed two to three days after placement, and this can cause mucosal abrasions or eschar detachments depending on the material used. The Merocel sponge, for example, may be excellent at immediate hemostasis, but it's less of a friend on removal day. By contrast, the Rapid Rhino, an inflatable balloon coated with hydrocolloid fabric that, once wet, forms a gel that seems to stay better lubricated.
“Several RCTs have found that Rapid Rhino causes less bleeding and pain during removal than [traditional nasal packing], Merocel, or Rhino Rocket ... and is easier to remove for the health care provider,” the authors reported. “Similar reasons may explain why TXA was ranked superior to Merocel, [traditional nasal packing], and Rhino Rocket in terms of 2-day rebleeding as an outcome: Because no nasal packing needs to be removed in [isolated] TXA treatment, there is no risk of mucosal injury or eschar detachment.”
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Dr. Bivensworks at emergency departments in Massachusetts, including St. Luke's in New Bedford and Beth Israel Deaconess Medical Center in Boston. He is double-boarded in emergency medicine and addiction medicine. Follow him on Twitter@matt_bivens.
