Well, it’s not the major hemorrhage of CRASH-2 – but, as every Emergency Physician knows, refractory epistaxis is burdensome and significantly irritating to all involved. Luckily, there are a variety of methods available to manage bleeding, mostly successful.
You may now add tranexamic acid to this list. TXA, an antifibrinolytic agent, already used to reduce hemorrhage-associated coagulopathy, has been used in many different forms for minor bleeding as well. These folks from Iran randomized, in unblinded fashion due to differences in odor, folks presenting with severe epistaxis to “conventional control” with cotton pledgets soaked in lidocaine + epinephrine versus pledgets soaked with 500mg of TXA. Sadly, they do not declare a primary outcome – rather, the authors list several “efficacy variables” – but, whichever they would have chosen, it would have favored the TXA group. 71% of TXA patients had cessation of bleeding within 10 minutes, versus 31% with lidocaine+ epinephrine, faster discharge from the ED, less rebleeding in 24 hours, and less rebleeding at a week.
It seems physiologically plausible, in any event, considering lidocaine+epinephrine isn’t truly directly therapeutic for hemostasis. As any Emergency Physician knows, it’s all about Plan B, C & D for every situation – and TXA seems another reasonable tool for the box.
“A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial”
http://www.ncbi.nlm.nih.gov/pubmed/23911102