Standing on the corner, minding my own business in the ER

Novel therapies for Anterior Epistaxis (Calgary EM Journal Club)

Nosebleedpulpfiction

Epistaxis can be managed in many ways, from a simple squeeze of the nose to stuffing it with a tampon, and everything in between.  Today we’ll look at two novel methods of managing anterior epistaxis, one of which has become my go to for the moderate, non-anticoagulated bleeder.  Both of these techniques obviate the need for packing and are thus very popular among both patients and physicians.  These articles were reviewed at the University of Calgary EM Journal Club, May 2014.

For a review of epistaxis and a solid general approach, here are a few options:

1)The Skeptics Guide to Emergency Medicine (TheSGEM.com) Episode #53 “Sunday, Bloody Sunday” - Ken reviews the basics and one of the articles we’ll discuss here today.

2)For a very thorough approach, check out Schlosser’s NEJM review of epistaxis from 2009. (Subscription required)

TXAampouleimage
Option #1 – Tranexamic Acid

The first new option for epistaxis is topical application of the IV form of tranexamic acid.  Incredibly easy to do, just take an ampoule of TXA (1 gram/10 mL) and soak 15 cm of cotton pledget/gauze with 500 mg (5 mL) of the TXA solution.  Stuff it up the nostril, get them to pinch the nose for 15 minutes and come back.  The bonus is that you have 500 mg for the other nostril in the same vial, so feel free to do both.

This technique was far superior to traditional packing in terms of ED length of stay, patient/physician satisfaction, and had no increased rate of re-bleed at 7 days.  I have personally found this technique tremendously successful in my limited use thus far.  1 of 4 patients failed, but their INR would have precluded them from the study anyway.

NB. Patients with an INR > 1.5 were excluded from this study. See BEEM Commentary section.

Full journal article critical appraisal is below.

Flosealimage
Option #2 – Floseal Hemostatic Matrix

The second new option is actually not so new.  It comes from a 2005 paper in Laryngoscope and compares the use of Floseal gel matrix to traditional packing.  Floseal is a product similar to Gelfoam, Surgicel, etc. used for hemostasis, except it does not require platelet activation like the others.  This is theoretically fantastic as many of our epistaxis patients are on ASA/Clopidogrel or other anti-platelet agents.  Notably, this study included patients with INRs up to 4.5 and had fewer exclusion criteria than the TXA study.

This was a small, 70 patient study with industry sponsorship (BTW, I get paid nothing by anyone!) that showed improved patient/physician satisfaction, reduced head and neck surgery (HNS) consultation rates and decreased re-bleed rates in the Floseal group.

My main issue with the Floseal study is that I don’t have Floseal!! I’m not sure if anyone else has experience with this product, would love to hear your comments if you do.  It looks to be about $165/application, which although more than a nasal tampon, probably pays for itself with reduced re-visits and HNS consults.  However, I could just use TXA for many of these patients and it costs pennies.

Full article critical appraisal is below.

Article #1

A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial

Clinical Question:Is topical tranexamic acid (TXA) superior to traditional nasal packing for the treatment of anterior epistaxis?

Reference:American Journal of Emergency Medicine 31 (2013) 1389–1392

PubMed ID:23911102

Population:   Adult ED patients (n=216)

Intervention: 15 cm cotton pledget soaked in injectable TXA (500 mg in 5 mL) inserted into the bleeding nostril.

Comparison: Cotton pledget soaked in epiephrine (1:100000) + lidocaine (2%) for 10 minutes followed by packing with cotton pledgets coated in tetracycline.

Outcome:     Cessation of epistaxis within 10 minutes, rebleeding at 24 hours and 7 days, length of stay (LOS) and patient satisfaction.
Authors’ Conclusions: “Treating anterior epistaxis with the topical use of injectable form of tranexamic acid is better than usual nasal packing”.

Quality Checklist:

1. The study population included or focused on those in the ED.  Yes.

2. The patients were adequately randomized. Yes.

3. The randomization process was concealed.  Yes.

4. The patients were analyzed in the groups to which they were randomized. Yes.

5. The study patients were recruited consecutively (i.e. no selection bias).  Unsure.

6. The patients in both groups were similar with respect to prognostic factors.  No.

7. All participants (patients, clinicians, outcome assessors) were unaware of group allocation.  No.

8. All groups were treated equally except for the intervention. Yes.

9. Follow-up was complete (i.e. at least 80% for both groups). Yes.

10. All patient-important outcomes were considered. Yes.

11. The treatment effect was large enough and precise enough to be clinically significant.  Yes.  

Key Results:

Outcome TXA (%) Anterior nasal packing Odds Ratio (95% CI) p-value
Bleeding stopped < 10 min 71 31.2 2.28 (1.68-3.09) <0.001
Discharge <2 hours 95.3 6.4 14.8 (7.2-30.4) <0.001
Complications 4.7 11 0.42 (0.15-1.16) 0.128
Re-bleed at 24 hrs 4.7 12.8 0.36 (0.14-0.98) 0.034
Re-bleed at 1 week 2.8 11 0.26 (0.07-0.88) 0.018
Patient satisfaction 85 44 <0.001

 

BEEM Commentary:

The patients in the TXA group had a much higher rate of previous epistaxis (58.1% vs. 13.6%) compared with the packing group. This could alter the authors conclusions. Physicians were not blinded to treatment group which is a potential source of bias. Finally, many groups were excluded in this study, including, INR >1.5, visible bleeding vessel, major trauma, pre-existing coagulopathy and posterior bleeds.

Comments on author’s conclusion compared to BEEM conclusion:

This study did show positive outcomes with using tranexamic acid for anterior epistaxis, although many patient groups were excluded from the study.

The Bottom Line:

TXA seems to be a good alternative to nasal packing for earlier patient discharge and improved patient satisfaction.

Clinical Application:

Consider using a TXA soaked cotton pledget for your next anterior epistaxis patient.

What do I tell my patients?

We have several options for treating your nosebleed. One of them is to soak some cotton with a medication called tranexamic acid and leave it in your nose for 10-15 minutes. If it works, it will allow you to go home sooner and without nasal packing that has to be removed in a few days. 

Reviewers: Chris Bond and Ken Milne

 

Article #2 

Prospective, Randomized, Controlled Clinical Trial of a Novel Matrix Hemostatic Sealant in Patients with Acute Anterior Epistaxis

Clinical Question:How does Floseal Matrix Hemostatic Sealant (Floseal) compare to nasal packing for the treatment of anterior epistaxis?

Reference:Laryngoscope. 2005 May;115(5):899-902.

PubMed ID:15867662

Population:   Adults (>18) with acute anterior epistaxis (n=70)

Intervention: Floseal Matrix Hemostatic Sealant

Comparison: Traditional nasal packing (eg. Merocel, Vaseline gauze, Rhinorocket, etc.)

Outcome:      Patient level of comfort and satisfaction, MD assessed effectiveness, ease of use and satisfaction, HNS (head and neck suregery) surgery consult rate, rebleed rate and crossover into other group.

Authors’ Conclusions: Floseal is more effective than nasal packing in treating patients with acute anterior epistaxis.

Quality Checklist:

1. The study population included or focused on those in the ED.  Yes.

2. The patients were adequately randomized.  Yes.

3. The randomization process was concealed. Yes.

4. The patients were analyzed in the groups to which they were randomized. Yes.

5. The study patients were recruited consecutively (i.e. no selection bias). Unsure.                                    

6. The patients in both groups were similar with respect to prognostic factors.  Yes. 

7. All participants (patients, clinicians, outcome assessors) were unaware of group allocation.  No.

8. All groups were treated equally except for the intervention.  No.

9. Follow-up was complete (i.e. at least 80% for both groups).  Unsure.

10. All patient-important outcomes were considered.   Yes.

11. The treatment effect was large enough and precise enough to be clinically significant.   Yes.

Key Results:

Reduced rate of HNS consult in Floseal group (8.6% vs. 31%, p<0.05), reduced rebleed rate within 7 days (14% vs 40%, p<0.05), reduced rebleed at follow-up visit (0% vs. 63%, p<0.001) and increased crossover in the packing group (23% vs. 3%, p<0.05).  Patient comfort and satisfaction was much better in the Floseal group, as was MD assessed effectiveness, ease of use and satisfaction (all p<0.001).

BEEM Commentary:

While the results are compelling, this study does have several limitations.  This was an industry funded,  non-blinded study and thus the MD and patient questionnaires are at significant risk for bias.   Furthermore, this was a small study (70 patients) and the primary outcome was not specified. We also do not know if patients were recruited consecutively, and are unsure of which group the crossover patients (23% in the packing arm) were analyzed in.  Other treatment (such as hypertension) was left to the discretion of the treating physician. Floseal is significantly more expensive than traditional packing methods ($165/application), however, this cost is likely offset by the decreased need for HNS consultation and lower rebleed rate.

Comments on author’s conclusion compared to BEEM conclusion:

Although the study does suffer from several limitations, it would be difficult to blind patients to gel matrix vs. packing, and Floseal for anterior epistaxis seems to be a reasonable option.

The Bottom Line:

Floseal is a potentially useful option for the management of anterior epistaxis.

Clinical Application:

Floseal offers another alternative in the management of anterior epistaxis.

What do I tell my patients?

We have several options for managing your nosebleed.  One of them is to insert a gel like substance into the nostril to stop the bleeding.  If it works, it will be more comfortable than inserting nasal packing and won’t increase your chance of rebleeding. 

Reviewers:Chris Bond

 

Questions? Experience with Floseal, Surgicel, etc. for epistaxis?  Please comment below.

Cheers,

Chris

@socmobem

 

References:

Schlosser RJ.  Clinical Practice: Epistaxis. N Engl J Med. 2009 Feb 19;360(8):784-9. doi: 10.1056/NEJMcp0807078.

Zahed RMoharamzadeh PAlizadeharasi SGhasemi ASaeedi MAmerican Journal of Emergency Medicine 31 (2013) 1389–1392

Mathiasen RA, Cruz RM. Laryngoscope. 2005 May;115(5):899-902.

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