Three Part Question
In [adult patients with spontaneous epistaxis] do we need to [routinely test coagulation] to [rule out coagulation abnormalities]
A 64 year old male presents with epistaxis. Your usual approach is to attain haemostasis, check for hypertension and coagulopathy. As you prepare to gain IV access and take blood you wonder whether there is any evidence to show that checking the clotting is warranted.
Ovid MEDLINE(R) 1948 to March Week 4 2011. EMBASE via the NHS Evidence ‘Health Information Resources’ date of searching 31/03/2011. The Cochrane Library March 2011
Medline:[Exp epistaxis/] AND [exp International normalized ratio/ OR exp Prothrombin time/ OR exp Partial Thromboplastin Time/ OR exp Blood Clotting Test/ ] LIMIT to english language and humans
EMBASE:[epistaxis.ti] AND [exp International normalized ratio/ OR exp Prothrombin time/ OR exp Partial Thromboplastin Time/ OR exp Blood Clotting Test/ ] LIMIT to english language and humans
Cochrane: Epistaxis [mesh] 87 records none relevant
63 papers were identified from Medline and an additional 19 from Embase. 3 were of sufficient quality for inclusion.
|Author, date and country
||Study type (level of evidence)
|Jackson et al,|
|75 consecutive patients referred to one of the two authors after initial evaluation and treatment failure by primary care physicians ||Observational||To identify underlying factors associated with active refractory epistaxis||Only patients with liver disease or treated with vitamin K antagonists had abnormal coagulation||Small numbers
Does not indicate how many patients had abnormal coagulation|
|Thaha et al,|
|121 patients admitted with epistaxis between January and December 1998 who had coagulation studies performed||Observational||Cause of abnormal coagulation||10 patients had abnormal coagulation and all were taking warfarin||Small numbers
|Awan et al,|
|108 patients aged >14 years with epistaxis, requiring admission between January 2002 and December 2005||Observational||To identify groups of patients likely to present with coagulation abnormalities||10 patients had abnormal coagulation of which, 6 patients receiving anticoagulant treatment, 2 had chronic active hepatitis, 1 had liver cancer and 1 had haemophilia ||Small numbers
Different patient population to the UK|
All studies have shown that in patients presenting with epistaxis, all those with abnormal coagulation have clear reasons for this identified in the medical history. All studies were of good quality but the number of patients with abnormal coagulation were small.
Clinical Bottom Line
Adult patients presenting to the ED with epistaxis only need to have coagulation studies performed if the history indicates a potential cause of coagulopathy
Level of Evidence
Level 2 - Studies considered were neither 1 or 3.
- Jackson KR, Jackson RT. Factors Associated With Active, Refractory Epistaxis Arch Otolaryngol Head Neck Surg 1988;114:862-865.
- Thaha MA, Nilssen EL, Holland S et al. Routine coagulation screening in the management of emergency admission for epistaxis – is it necessary? The Journal of Laryngology and Otology 2000; Vol. 114, pp. 38–40
- Awan MS, Iqbal M, Imam SZ. Epistaxis: when are coagulation studies justified? EMJ 2008; 25: 156-157