Evaluating effectiveness of nasal compression with tranexamic acid compared with simple nasal compression and Merocel packing: a randomized controlled trial
Akkan S, Corbacioglu SK, Aytar H, et al. Ann Emerg Med. 2019;74(1):72-78.
SUMMARY:
There are many ways to manage anterior epistaxis, including topical vasoconstrictors with nasal compression, silver nitrate sticks, and cauterization, but one of the most common methods uses anterior nasal packing, which works but is very uncomfortable and requires packing removal.
Tranexamic acid (TXA) is an antifibrinolytic agent used to increase hemostasis in major trauma and surgical interventions.
This study randomized 135 patients to 500 mg TXA diluted in 5 mL saline sprayed in each nostril via an atomizer followed by manual compression for 15 min, versus saline sprayed in each nostril followed by compression versus Merocel packing with 2% lidocaine for 24 h.
The success rate of stopping bleeding at 15 min was 91.1% in the TXA/compression group versus 71.1% in the saline/compression group and 93.3% in the packing group.
The rebleed rate was 13.3% in the TXA/compression group versus 40% in the saline/compression group and 26% in the packing group.
Though not a planned outcome, 15% of the packing group requested pack removal because of severe pain. The authors report that no patients were lost to follow-up.
This study is limited by the fairly small sample size, the exclusion of patients receiving antiplatelet agents, the use of Merocel packing rather than an alternative that might have been better tolerated (eg, Rhino Rockets), and the absence of examination of clots secondary to the treatment (eg, deep vein thrombosis).
EDITOR’S COMMENTARY: In this RCT, the authors found that atomized TXA at a dose of 500 mg diluted in 5 mL was as effective as nasal packing at stopping anterior epistaxis and was associated with higher patient comfort and less rebleeding. Both techniques worked better than compression alone. We are still not sure what the best way to use TXA is (soaked pledget or gel), but this seems like a reasonable option for a patient whom you don't want to pack.
Copyright 2019 by Emergency Medical Abstracts – All Rights Reserved 11/19 - #01
I thought it worth pointing out that the “perfume bottle” atomizers referred to in Abstract 1, Nov 2019 should not be used in medical practice because of their very high risk of internal contamination and risk of patient cross contamination. You should use a disposable atomizer or other form of administration to deliver TXA or any other nasal drug in the ED.
“Perfume atomizers” – the bottled medication with a bulb or compressed air supply energy source operate via the Venturi principle. The high pressure air is forced through a constriction at the device tip which creates a negative pressure (Venturi effect) and pulls drug up through a second internal lumen which is fragmented into a fine mist. However at the moment that airflow ceases the liquid within the second internal lumen collapses back into the bottle and creates suction on the second lumen. This results in aspiration of any contaminants at the tip into the second lumen and often into the liquid within the bottle. If you touch the patient with the tip of your atomizer you will contaminate the device with their secretions and these contaminants will probably be aspirated back into the perfume bottle. This has been demonstrated very convincingly in the lab and in clinical trials (see links to abstracts below – others exist). Venturi atomizer cross contamination was implicated as the cause of several TB cases in North Carolina reported in 2001 and another tuberculosis outbreak in Washington state about 10 years later. It has probably caused countless other infections that would be harder to track down than tuberculosis. If you are still using these in your practice, it is time to take them home for perfume administration and stop using them on your patients.
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Timothy R. W. - January 24, 2020 12:29 PM
I thought it worth pointing out that the “perfume bottle” atomizers referred to in Abstract 1, Nov 2019 should not be used in medical practice because of their very high risk of internal contamination and risk of patient cross contamination. You should use a disposable atomizer or other form of administration to deliver TXA or any other nasal drug in the ED.
“Perfume atomizers” – the bottled medication with a bulb or compressed air supply energy source operate via the Venturi principle. The high pressure air is forced through a constriction at the device tip which creates a negative pressure (Venturi effect) and pulls drug up through a second internal lumen which is fragmented into a fine mist. However at the moment that airflow ceases the liquid within the second internal lumen collapses back into the bottle and creates suction on the second lumen. This results in aspiration of any contaminants at the tip into the second lumen and often into the liquid within the bottle. If you touch the patient with the tip of your atomizer you will contaminate the device with their secretions and these contaminants will probably be aspirated back into the perfume bottle. This has been demonstrated very convincingly in the lab and in clinical trials (see links to abstracts below – others exist). Venturi atomizer cross contamination was implicated as the cause of several TB cases in North Carolina reported in 2001 and another tuberculosis outbreak in Washington state about 10 years later. It has probably caused countless other infections that would be harder to track down than tuberculosis.
If you are still using these in your practice, it is time to take them home for perfume administration and stop using them on your patients.
Wolfe: https://www.ncbi.nlm.nih.gov/pubmed/12222941
Ikeda: https://www.ncbi.nlm.nih.gov/pubmed/23120633
Southwick: https://www.ncbi.nlm.nih.gov/pubmed/11172311
Tim Wolfe, MD Retired