The medical world moves quickly and some treatments emerge, are in vogue and disappear in the blink of an eye (for example Xigris). Others emerge stay with us and extend their applicability over time. I suspect Tranexamic acid (TxA) will be one of those slow burners that stay around.
It has been recognised for some considerable time that the perioperative administration of TxA to patients who are likely to suffer significant intraoperative blood loss decreases transfusion requirement and mortality (1). The CRASH-2 trial published in 2010 (2) and the subsequent subgroup analysis (3) demonstrated a significant improvement in survival of trauma patients whose doctors had deemed it likely that they had experience or would experience significant haemorrhage. The benefits were seen in those groups that received the drug within 3 hours of injury and had maximal effect if delivered within 1 hour. The CRASH-2 collaborators report a 32% reduction in death due to bleeding when tranexamic acid is given within 1 h of injury.
Further comment has been forthcoming suggesting that the benefit may be less in advanced trauma systems where the early availability of advanced care including blood transfusion may limit the impact of TxA and that TxA may be of most use in the prehospital setting where definitive care may be delayed and in low resource environments (4). To this end the PATCH-Trauma study is aiming to recruit prehospital trauma patients from late 2013.
In the midst of this flurry of activity emerged a novel use for the intravenous TxA preparation. The treatment of epistaxis. The research emerged from an interesting source; Tehran University of Medical Sciences, via the American Journal of Emergency Medicine (5). A heartening example of medicine rising above ideological differences for the betterment of noses everywhere.
Epistaxis, is a common primary care and emergency presentation. The 2 populations at highest risk are those under the age of 10 years and in the 60s. epistaxis may occur secondary to surgery, trauma, hypertension, bleeding disorders, hereditary haemorrhagic telangiectasia, and antiplatelet and anticoagulation drug use, its aetiology is unknown in 70% to 80% of cases (6).
Epistaxis is usually self-limiting but can be life threatening, especially in elder patients or those with underlying conditions.
Currently, treatment of epistaxis includes squeezing the nose, using vasoconstrictor agents, chemical (silver nitrate) or electrical cauterization, and nasal packing with ribbon gauze or nasal tampon. Nasal packing is usually performed after application of an anaesthetic agent such as lignocaine and a vasoconstrictor.
Anterior nasal packing, as one of the most routine management for epistaxis, has some limitations including long stay of the pack causing local pressure effects.
The investigators in the trial recruited about 215 patients with spontaneous epistaxis, no known bleeding disorder, no vessel amenable to cauterisation or shock. 107 received treatment with a 15cm cotton pledget soaked with 500mg in 5ml TxA. The pledget was removed once bleeding stopped and no packing was used.
The other 109 patients were anteriorly packed with a pledget soaked with 1:10000 adrenaline with 2% lignocaine. The pack was removed after 10 minutes and replaced by an anterior pack soaked with tetracycline.
The analysis of the outcomes included time to arrest of haemorrhage, rebleed rates at 24hrs and 7 days and patient satisfaction.
Results
This seems to demonstrate a significant decrease in the time to arrest of bleeding and improvement in discharge times. The rebleed rates do not seem to be significantly different.
For more information we will be addressing “Epistaxis: Stop it quick in 3 steps!” at EMCore in Hong Kong and Fiji.
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Henry DA, Carless PA, Moxey AJ, et al. Anti-fi brinolytic use for minimising perioperative allogeneic blood transfusion. Cochrane Database Syst Rev 2007; 4: CD001886.
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CRASH-2 trial collaborators. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo controlled trial. Lancet 2010; 376: 23–32.
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CRASH-2 trial collaborators. The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomised controlled trial. Lancet 24th March 2011 online.
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PATCH-Trauma study investigators. Trauma and tranexamic acid. Research is needed to determine how patient selection and intercurrent treatment affect safety and efficacy, editorial comment; MJA 199 (5) · 2 September 2013
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Reza Zahed, Payman Moharamzadeh, Saeid AlizadehArasi, Asghar Ghasemi, Morteza Saeedi. A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial. American Journal of Emergency Medicine published online 01 August 2013.
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Stell PM. Epistaxis. Clin Otolaryngol Allied Sci 1977;2(3):263–73
