CLINICAL QUESTION: Does the application of topical tranexamic acid reduce bleeding as compared to anterior packing?
ARTICLE CHOSEN: Zahed R, Moharamzadeh P, Alizadeharasi S, et al. A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial. Am J Emerg Med 2013;31(9):1389-92.
OBJECTIVES: To determine if topically applied tranexamic acid reduces bleeding time in epistaxis.
OBJECTIVE: This study aimed to compare management, readmission rates and length of in-patient stay amongst warfarinised and non-warfarinised patients to ascertain future treatment protocols.
METHODS: A 12-month retrospective review was conducted of ENT epistaxis admissions. Admission details such as length of in-patient stay, clotting profile and management plan were recorded. Comparisons of management and outcome for warfarinised and non-warfarinised patients were made using the Fisher's exact paired t-test.
RESULTS: Of 176 epistaxis patients admitted, 31 per cent were warfarinised, 18 per cent were on another form of anticoagulation or antiplatelet therapy, and 51 per cent were not on any medication that might impose a bleeding risk. The international normalised ratio at admission was high in 13 per cent of warfarinised patients; the remaining patients had therapeutic or sub-therapeutic international normalised ratios and so warfarin was continued. The mean in-patient stay was similar for all cohorts; however, warfarinised patients had a higher readmission rate.
CONCLUSION: Warfarinised epistaxis patients may be safely managed without stopping their anticoagulation therapy, provided their international normalised ratio is at therapeutic or sub-therapeutic levels. By continuing regular anticoagulation therapy, warfarinised patients may be discharged without delay.
Epistaxis is a common indication for admission under ENT care. Such patients usually have nasal packing for a short period and social circumstances or medical co-morbidities may prevent discharge home with packs in-situ. With bed pressures and an elderly epistaxis population, these admissions are far from ideal but are unavoidable in those with significant bleeds. This article is protected by copyright. All rights reserved.
OBJECTIVE: To identify risk factors associated with spontaneous recurrent epistaxis.
PATIENTS AND METHODS: This was a retrospective cohort study assessing patients in the Marshfield Clinic system diagnosed as having epistaxis between January 1, 1991, and January 1, 2011. There were 461 cases with at least 2 episodes of spontaneous epistaxis within 3 years and 912 controls with only 1 episode in the same time frame. More than 50 potential risk factors were investigated, including demographic features, substance use, nasal anatomical abnormalities, nasal infectious and inflammatory processes, medical comorbidities, medications, and laboratory values. A Cox proportional hazards regression modeling approach was used to calculate hazard ratios of epistaxis recurrence.
RESULTS: Traditional risk factors for epistaxis, including nasal perforation, nasal septum deviation, rhinitis, sinusitis, and upper respiratory tract infection, did not increase the risk of recurrence. Significant risk factors for recurrent epistaxis included congestive heart failure, diabetes mellitus, hypertension, and a history of anemia. Warfarin use increased the risk of recurrence, independent of international normalized ratio. Aspirin and clopidogrel were not found to increase the risk of recurrence. Few major adverse cardiovascular events were observed within 30 days of the first epistaxis event.
CONCLUSION: Congestive heart failure is an underappreciated risk factor for recurrent epistaxis. Hypertension and diabetes mellitus may induce atherosclerotic changes in the nasal vessels, making them friable and more at risk for bleeding. Patients with recurrent epistaxis may also be more susceptible to developing anemia. Physicians should promote antiplatelet and antithrombotic medication adherence despite an increased propensity for recurrent epistaxis to prevent major adverse cardiovascular events.
OBJECTIVE: Epistaxis is a common problem in the emergency department (ED). Sixty percent of people experience it at least once in their life. There are different kinds of treatment for epistaxis. This study intended to evaluate the topical use of injectable form of tranexamic acid vs anterior nasal packing with pledgets coated with tetracycline ointment.
METHODS: Topical application of injectable form of tranexamic acid (500 mg in 5 mL) was compared with anterior nasal packing in 216 patients with anterior epistaxis presented to an ED in a randomized clinical trial. The time needed to arrest initial bleeding, hours needed to stay in hospital, and any rebleeding during 24 hours and 1 week later were recorded, and finally, the patient satisfaction was rated by a 0-10 scale.
RESULTS: Within 10 minutes of treatment, bleedings were arrested in 71% of the patients in the tranexamic acid group, compared with 31.2% in the anterior nasal packing group (odds ratio, 2.28; 95% confidence interval, 1.68-3.09; P < .001). In addition, 95.3% in the tranexamic acid group were discharged in 2 hours or less vs 6.4% in the anterior nasal packing group (P < .001). Rebleeding was reported in 4.7% and 11% of patients during first 24 hours in the tranexamic acid and the anterior nasal packing groups, respectively (P = .128). Satisfaction rate was higher in the tranexamic acid compared with the anterior nasal packing group (8.5 ± 1.7 vs 4.4 ± 1.8, P < .001).
CONCLUSIONS: Topical application of injectable form of tranexamic acid was better than anterior nasal packing in the initial treatment of idiopathic anterior epistaxis.
Epistaxis is one of the most frequent emergencies in rhinology. Patients using anticoagulative medication are at increased risk for epistaxis. We evaluated the prothrombin time and the international normalized ratio (INR) in anticoagulated epistaxis patients. Patients suffering from epistaxis were prospectively included in a database and results from prothrombin testing were analyzed in the context of anticoagulation. One hundred sixteen of 591 epistaxis cases were identified to be on oral anticoagulation. The INR was found to be above therapeutic levels in 19 (16%) of these cases. We strongly recommend prothrombin time and INR testing in all epistaxis patients taking any sort of vitamin K antagonists.
Revista»Clinical otolaryngology : official journal of ENT-UK ; official journal of Netherlands Society for Oto-Rhino-Laryngology & Cervico-Facial Surgery
OBJECTIVES: Epistaxis can be caused or exacerbated by anticoagulant and antiplatelet therapy. This prospective study assessed the prevalence of epistaxis in patients taking anticoagulant and antiplatelet medication, and monitored differences in patients' clinical courses.
METHOD: Prospective data were collected for consecutive patients referred with epistaxis from the emergency department over a seven-month period. Emergency department records were used to investigate prevalence and referral rates.
RESULTS: Over the study period, 290 patients presented to the emergency department with epistaxis; this represented 0.9 per cent of all emergency attendances. Of these patients, 119 (39 per cent) were referred on to the ENT department, 62 per cent of whom were currently taking anticoagulant or antiplatelet medication. Patients taking anticoagulant and antiplatelet medication were a significantly older group (relative risk 1.50 (1.08-2.28), p = 0.01) requiring longer in-patient stays (relative risk 2.50 (1.01-4.97), p = 0.01) and more aggressive local haemostasis measures. Most patients taking warfarin had an international normalised ratio outside the appropriate range for their disease. Hypertension was not a factor in these patients' clinical course.
CONCLUSION: Increasingly, emergency and ENT departments are being presented with epistaxis in patients taking anticoagulant or antiplatelet medication. A better understanding of such medication and its effects may enable more effective management of these patients.
Does the application of topical tranexamic acid reduce bleeding as compared to anterior packing?
ARTICLE CHOSEN:
Zahed R, Moharamzadeh P, Alizadeharasi S, et al. A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial. Am J Emerg Med 2013;31(9):1389-92.
OBJECTIVES:
To determine if topically applied tranexamic acid reduces bleeding time in epistaxis.
