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Three Part Question

In [adults with uncomplicated acute epistaxis] is [intravenous tranexamic acid better than standard treatments alone] at [reducing bleeding volume and time]?

Clinical Scenario

A 74-year-old woman presents to the emergency department with significant primary epistaxis. She struggles to tolerate nasal packing. A passing orthopaedic registrar suggests that tranexamic acid may be beneficial since it works in other haemorrhage scenarios. You wonder if he is correct and whether there is any evidence for a role for intravenous tranexamic acid in the management of her epistaxis.

Search Strategy

Medline using the NHS Evidence interface 1946 to present date of searching 14/04/15

EMBASE using the NHS Evidence interface 1974 to present date of searching 14/04/15 Using multifile searching:

(exp EPISTAXIS/ OR nose bleed, ti,ab) AND (exp ADMINISTRATION, INTRAVENOUS/ OR exp INFUSIONS, INTRAVENOUS/ OR exp INJECTIONS, INTRAVENOUS/ AND exp Tranexamic Acid/) 7 results

The Cochrane Library Issue 4 of 12 April 2015: MeSH descriptor: [Tranexamic Acid] explode all trees AND MeSH descriptor: [Epistaxis] explode all trees 4 records 0 directly relevant

Search Outcome

Seven papers were found, of which none answered the clinical question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses

Comment(s)

There is a distinct lack of studies on this topic. The current literature would support a role for intravenous tranexamic acid in elective surgery, with the wealth of literature being in orthopaedic surgery—although a recent study has shown benefit in ENT for endoscopic sinus surgery patients (Alimain and Mohseni1) and another study has shown benefit in topical administration in anterior epistaxis (Zahed et al2). There is good evidence for the benefit of oral tranexamic acid in patients with epistaxis, particularly those with known clotting or bleeding disorders. There is evidence for the use of intravenous tranexamic acid in major traumatic haemorrhage; however, this appears to be limited by how quickly treatment is given after onset of bleeding. Extrapolating all of this evidence, there may be a role for intravenous tranexamic acid in the management of severe epistaxis; however, the extent of this is currently unclear.

Clinical Bottom Line

There is no evidence available to answer the clinical question. Local advice should be followed.

References

1. Alimain M, Mohseni M. The effect of intravenous tranexamic acid on blood loss and surgical field quality during endoscopic sinus surgery: a placebo-controlled clinical trial Clin Anaesth 2011;23:611–15.
2. ahed R, Moharamzadeh P, Alizadeharasi S, et al. A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial. Am J Emerg Med 2013;31:1389–92.