I've done my share of bootlegging. Up 'ere, if you engage in
what the federal government calls 'illegal activity,' but what we call 'just a
man tryin' to make a livin' for his family sellin' moonshine liquor,' it behooves
oneself to keep his wits. Long story short, we hear a story too good to be
true... it ain't. Lt Aldo Raine
“Inglourious Basterds” 2009
This
study out of Tehran, Iran looked at using the injectable form of tranexamic
acid (TXA) to control uncomplicated anterior epistaxis.
This
was a single centre unblinded randomized controlled trial. In the experimental
group a 15cm piece of cotton pledget was soaked in tranexamic acid (500mg/5ml) and was inserted in the nostril. It was
removed shortly after it was
determined that the bleeding had stopped. The control group had standard anterior nasal packing that
was removed after 3 days.
216
patients were randomized and there was no loss to follow up. The methods did
not really specify a primary outcome but they did report numerous “efficacy
variables.”
Within
10 minutes of treatment, the bleeding had stopped in 71% of the TXA group compared
with 31% of the control. In addition, 95%
of those treated with TXA were discharged from the ED in 2 hours or less
compared to 6% in the controls.
This
treatment effect is way too good to be
true. There must have been some systematic bias that accounted for the
profound differences in early discharge of the TXA group. This is never really
explained in the discussion section of the paper.
The
numerous grammatical errors in the text do make the paper appear a bit sloppy
and hard to read. It should be the job of the journal editor to ensure that these
errors do not make it to print.
Unfortunately,
this study excluded complicated epistaxis. These are precisely the patients who
may require some extra finesse and it would be nice to know if there was some efficacy
of TXA in this population.
Despite
all of this, I think the notion of topical TXA treatment for epistaxis is
compelling. Many other large studies over decades have shown it to be
reasonably safe. Not only is TXA
unlikely to cause harm but it is dirt cheap. We have vials of TXA in my ED that
cost $6 a vial.
The
bottom line? I think it is reasonable to
try the injectable form of TXA topically as an adjunct to help control
epistaxis. Why not? But please don’t
expect the miracle cure that this paper purports.
Covering:
Zahed
R, Moharamzadeh P, AlizadehArasi S, et al. A new and rapid method for epistaxis
treatment using injectable form of trenexamic acid topically: a randomized
controlled trial. Am J Emerg Med 2013; 31:1389-1392.
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