Tranexamic Acid in the ED

A quick case: A 57 y/o F with a PMH of DM, HTN, and Afib on warfarin presents to the emergency department (ED) complaining of spitting out a blood clot when she woke up in the morning. Upon waking she felt something in her mouth, spit out a small blood clot, and continued to have slow oral bleeding over the next several hours leading to presentation in the ED. She is not able to see where the blood is coming from, denies any other symptoms and states her last INR was 2.3. All other ROS is negative. On physical exam, it is noted that the patient has a broken upper left molar that is slowly bleeding.  All other physical exam and vitals were normal. The attending physician suggested using tranexamic acid (TXA) for treatment. But what’s that? I didn’t learn about that in med school.

Clinical Question: What studied uses are there for tranexamic acid in the Emergency Department?

Answer: After literature review, it seems that TXA has been studied in a wide variety of settings, but its use in the ED has only been minimally studied. There is ample evidence for its use in orthopedic procedures, vaginal bleeding, and dental surgery, but has only been looked at in one specific setting in the ED, epistaxis.


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

Methods:

  • Randomized control trial
  • 216 patients with anterior epistaxis in the ED randomized into 2 groups: anterior nasal packing (ANP) with epinephrine, lidocaine, and tetracycline or topical application of injectable form of TXA (500mg in 5 ml)

Results:

  • Within 10 minutes, 71% of TXA group vs 31.2% of ANP group had cessation of bleeding
  • 95.3% in TXA vs 6.4% in ANP were discharged home in 2 hours or less
  • Rebleeding within the first 24 hours was reported in 4.7% of TXA vs 12.8% of ANP
  • Rebleeding within 1 week was reported in 2.8% of TXA and 11% of ANP
  • Satisfaction rates were higher in patients receiving TXA

Author conclusions:

  • Treating anterior epistaxis with the topical use of injectable form of TXA is better than usual nasal packing

Limitations:

  • Posterior epistaxis was excluded
  • Severity of bleeding was not recorded/classified
  • Subjects and providers were not blinded
  • Relatively small sample size
  • Patients with bleeding disorders and elevated INR were excluded

Back to our case:
Our patient was treated with swish and spit TXA dissolved in normal saline. Patient was advised to swish the solution for 2 minutes, spit, and then repeat one more time. The patient’s bleeding resolved and was discharged home with dental follow-up. 

My conclusions:
It is clear that there is a role for TXA in the ED in the setting of epistaxis. It is also clear that there needs to be further research and evidence for its use in treatment of other disorders specifically in the ED. The extrapolation of results from other studies performed outside the ED are promising, but further evaluation needs to be performed before TXA’s use can become commonplace in the ED.

References:

  1. Zahed, R. et al.  A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial. American Journal of Emergency Medicine. 2013; 31: 1389-1392. Accessed August 1, 2014.
  2. Topical tranexamic acid for epistaxis or oral bleeds. R.E.B.E.L EM http://rebelem.com/topical-tranexamic-acid-epistaxis-oral-bleeds/

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