Epistaxis - Revision history

Danbot: Add MedicationDose entry (tranexamic acid topical) with SMW annotations

2026-03-20T18:29:21Z

Add MedicationDose entry (tranexamic acid topical) with SMW annotations

@@ Line 111: / Line 111: @@
 **Injectable form of tranexamic acid (500mg/5mL), not the dilute form
 **Can consider adding Epinephrine to non-absorbable packing to assist with vasoconstriction
 ==Disposition==

Rossdonaldson1 at 19:49, 26 April 2023

2023-04-26T19:49:15Z

← Older revision		Revision as of 19:49, 26 April 2023
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	[[File:Arteries of the Nose.jpg\|thumb\|The arteries that supply Kiesselbach's plexus (responsible for anterior nosebleeds).]]		[[File:Arteries of the Nose.jpg\|thumb\|The arteries that supply Kiesselbach's plexus (responsible for anterior nosebleeds).]]
	[[File:PMC3895177 270 2013 776 Fig1 HTML.png\|thumb\|Schematic arterial supply of the sinonasal cavity. The majority of the posterior epistaxis episodes arise from the septum. The arterial branches involved in epistaxis include the internal maxillary artery, the facial artery, and the ophthalmic artery.]]		[[File:PMC3895177 270 2013 776 Fig1 HTML.png\|thumb\|Schematic arterial supply of the sinonasal cavity. The majority of the posterior epistaxis episodes arise from the septum. The arterial branches involved in epistaxis include the internal maxillary artery, the facial artery, and the ophthalmic artery.]]

	===Types===		===Types===
	*Anterior		*Anterior
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	===[[Tranexamic acid]]===		===[[Tranexamic acid]]===
	''*The NoPAC trial showed no difference in anterior packing rates with or without topical TXA. Higher quality evidence than prior studies.<ref>Reuben A, Appelboam A, Stevens KN, et al. The use of tranexamic acid to reduce the need for nasal packing in epistaxis (Nopac): randomized controlled trial. Annals of Emergency Medicine. 2021;77(6):631-640.</ref>''		''*The NoPAC trial showed no difference in anterior packing rates with or without topical [[TXA]]. Higher quality evidence than prior studies.<ref>Reuben A, Appelboam A, Stevens KN, et al. The use of tranexamic acid to reduce the need for nasal packing in epistaxis (Nopac): randomized controlled trial. Annals of Emergency Medicine. 2021;77(6):631-640.</ref>''
	*500mg TXA applied to topical foam or non-absorbable packing and inserted into nares.<ref>Zahed R. 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 Sep;31(9):1389-92</ref>		*500mg [[TXA]] applied to topical foam or non-absorbable packing and inserted into nares.<ref>Zahed R. 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 Sep;31(9):1389-92</ref>
	**Injectable form of tranexamic acid (500mg/5mL), not the dilute form		**Injectable form of tranexamic acid (500mg/5mL), not the dilute form
	**Can consider adding Epinephrine to non-absorbable packing to assist with vasoconstriction		**Can consider adding Epinephrine to non-absorbable packing to assist with vasoconstriction

Zbuchwald: /* Tranexamic acid */

2023-04-24T00:17:22Z

Tranexamic acid

← Older revision		Revision as of 00:17, 24 April 2023
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	===[[Tranexamic acid]]===		===[[Tranexamic acid]]===
	''*The NoPAC trial showed no difference in anterior packing rates with or without TXA. Higher quality evidence than prior studies.<ref>Reuben A, Appelboam A, Stevens KN, et al. The use of tranexamic acid to reduce the need for nasal packing in epistaxis (Nopac): randomized controlled trial. Annals of Emergency Medicine. 2021;77(6):631-640.</ref>''		''*The NoPAC trial showed no difference in anterior packing rates with or without topical TXA. Higher quality evidence than prior studies.<ref>Reuben A, Appelboam A, Stevens KN, et al. The use of tranexamic acid to reduce the need for nasal packing in epistaxis (Nopac): randomized controlled trial. Annals of Emergency Medicine. 2021;77(6):631-640.</ref>''
	*500mg TXA applied to topical foam or non-absorbable packing and inserted into nares.<ref>Zahed R. 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 Sep;31(9):1389-92</ref>		*500mg TXA applied to topical foam or non-absorbable packing and inserted into nares.<ref>Zahed R. 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 Sep;31(9):1389-92</ref>
	**Injectable form of tranexamic acid (500mg/5mL), not the dilute form		**Injectable form of tranexamic acid (500mg/5mL), not the dilute form

Hoxbox: /* Chemical Cauterization */

2021-08-19T11:08:40Z

Chemical Cauterization

← Older revision		Revision as of 11:08, 19 August 2021
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	#*Leave on for a few seconds at most		#*Leave on for a few seconds at most
	#*Never cauterize both sides of the septum at one go (risk of septal perforation)		#*Never cauterize both sides of the septum at one go (risk of septal perforation)
			#*[https://www.nejm.org/doi/full/10.1056/NEJMvcm2020073 Video of silver nitrate cauterization].

	===Thrombogenic Foams===		===Thrombogenic Foams===

Rossdonaldson1: /* Management */

2021-05-27T17:42:02Z

Management

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 #Traditional Packing
 #*Apply ribbon gauze in accordion-like manner
 ===Posterior Nasal Packing===
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 *#Inflate with additional 5-7cc of saline to complete the pack
 *Keep packing for 72-96 hours, <48 hours associated with increased re-bleed.
 ==Disposition==

Rontluu: /* Tranexamic acid */

2021-05-24T13:18:05Z

Tranexamic acid

← Older revision		Revision as of 13:18, 24 May 2021
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	*Higher success rate by 10 minutes compared to anterior packing in patients on Aspirin or Plavix<ref>Zahed R et al. Topical Tranexamic Acid Compared With Anterior Nasal Packing for Treatment of Epistaxis in Patients Taking Antiplatelet Drugs: Randomized Controlled Trial. Acad Emerg Med 2017.</ref>		*Higher success rate by 10 minutes compared to anterior packing in patients on Aspirin or Plavix<ref>Zahed R et al. Topical Tranexamic Acid Compared With Anterior Nasal Packing for Treatment of Epistaxis in Patients Taking Antiplatelet Drugs: Randomized Controlled Trial. Acad Emerg Med 2017.</ref>
	* NNT of 5 for preventing one episode of rebleeding without adverse events. <ref>[https://www.thennt.com/nnt/tranexamic-acid-treatment-epistaxis/ Tranexamic Acid for the Treatment of Epistaxis theNNT.com]</ref><ref>[https://www.ncbi.nlm.nih.gov/pubmed/30933392 Gottlieb et al Tranexamic Acid for the Treatment of Epistaxis Acad Emerg Med. 2019 Nov;26(11):1292-1293]</ref>		* NNT of 5 for preventing one episode of rebleeding without adverse events. <ref>[https://www.thennt.com/nnt/tranexamic-acid-treatment-epistaxis/ Tranexamic Acid for the Treatment of Epistaxis theNNT.com]</ref><ref>[https://www.ncbi.nlm.nih.gov/pubmed/30933392 Gottlieb et al Tranexamic Acid for the Treatment of Epistaxis Acad Emerg Med. 2019 Nov;26(11):1292-1293]</ref>
			*The NoPAC trial showed no difference in anterior packing rates with or without TXA. Higher quality evidence than prior studies.<ref>Reuben A, Appelboam A, Stevens KN, et al. The use of tranexamic acid to reduce the need for nasal packing in epistaxis (Nopac): randomized controlled trial. Annals of Emergency Medicine. 2021;77(6):631-640.</ref>

	===Posterior Nasal Packing===		===Posterior Nasal Packing===

Masoodrm: /* Thrombogenic Foams */

2021-03-13T22:48:52Z

Thrombogenic Foams

← Older revision		Revision as of 22:48, 13 March 2021
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	===Thrombogenic Foams===		===Thrombogenic Foams===
	#Apply Gelfoam or Surgicel on visualized bleeding mucosa		#Apply Gelfoam or Surgicel on visualized bleeding mucosa
	#~~Bioabsorbable~~ so removal/antibiotics not needed		#These materials are bioabsorbable so removal/antibiotics not needed

	===Anterior Nasal Packing===		===Anterior Nasal Packing===
	''Only use if all of the above have failed''		''Only use if all of the above have failed''

Masoodrm: /* Direct Nasal Pressure */

2021-03-13T22:43:06Z

Direct Nasal Pressure

← Older revision		Revision as of 22:43, 13 March 2021
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	===Direct Nasal Pressure===		===Direct Nasal Pressure===
	#Have patient blow nose to expel clots ~~or suction nose~~		#Have patient blow nose or use suction to expel clots
	#Instill topical vasoconstrictor ([[oxymetazoline]] or [[phenylephrine]])		#Instill topical vasoconstrictor ([[oxymetazoline]] or [[phenylephrine]])
	#Have patient apply direct pressure over cartilaginous area of nasal bridge (not the bony area)		#Have patient apply direct pressure over cartilaginous area of nasal bridge (not the bony area)
			#*Can use 2 tongue depressors taped together on one end to create a makeshift device to pinch the nose
			#*Attempt direct pressure for at least 20 minutes before moving to additional modalities
	#Patient must lean forward to avoid blood draining down nasopharynx thus preventing desired tamponade		#Patient must lean forward to avoid blood draining down nasopharynx thus preventing desired tamponade

Masoodrm: /* Tranexamic acid */

2021-03-13T22:38:35Z

Tranexamic acid

← Older revision		Revision as of 22:38, 13 March 2021
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	===[[Tranexamic acid]]===		===[[Tranexamic acid]]===
	*500mg TXA applied to topical foam or non absorbable packing and inserted into nares.<ref>Zahed R. 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 Sep;31(9):1389-92</ref>		*500mg TXA applied to topical foam or non-absorbable packing and inserted into nares.<ref>Zahed R. 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 Sep;31(9):1389-92</ref>
	*~~injectable~~ form of tranexamic acid (500mg/5mL)not the dilute form		*Can consider adding Epinephrine to non-absorbable packing to assist with vasoconstriction
			*Injectable form of tranexamic acid (500mg/5mL)not the dilute form
	*Can stop bleeding as fast as 10 minutes		*Can stop bleeding as fast as 10 minutes
	*Higher success rate by 10 minutes compared to anterior packing in patients on Aspirin or Plavix<ref>Zahed R et al. Topical Tranexamic Acid Compared With Anterior Nasal Packing for Treatment of Epistaxis in Patients Taking Antiplatelet Drugs: Randomized Controlled Trial. Acad Emerg Med 2017.</ref>		*Higher success rate by 10 minutes compared to anterior packing in patients on Aspirin or Plavix<ref>Zahed R et al. Topical Tranexamic Acid Compared With Anterior Nasal Packing for Treatment of Epistaxis in Patients Taking Antiplatelet Drugs: Randomized Controlled Trial. Acad Emerg Med 2017.</ref>

Masoodrm: /* Anterior Epistaxis */

2021-03-13T22:37:20Z

Anterior Epistaxis

← Older revision		Revision as of 22:37, 13 March 2021
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	==Disposition==		==Disposition==
	===Anterior Epistaxis===		===Anterior Epistaxis===
	*~~consider~~ checking ~~Hgb~~ to ensure no significant blood loss anemia		*Consider checking hemoglobin to ensure no significant blood loss anemia
	*Discharge after ~~1hr~~ of observation		*Discharge after 1 hour of observation
	*Patients with therapeutic ~~warfarin levels~~ may continue medication		*Patients on Warfarin with therapeutic INR may continue medication
	*Discontinue [[NSAIDs]] for 3-4d		*Discontinue [[NSAIDs]] for 3-4 days
	*Possible [[amoxicillin-clavulanate]] if anterior packing was placed as prophylaxis for bacterial sinus infection or [[Toxic shock syndrome]] although no robust evidence base<ref>Cohn B. Are prophylactic antibiotics necessary for anterior nasal packing in epistaxis? Ann Emerg Med. 2015 Jan;65(1):109-11</ref>		*Possible [[amoxicillin-clavulanate]] if anterior packing was placed as prophylaxis for bacterial sinus infection or [[Toxic shock syndrome]] although no robust evidence base<ref>Cohn B. Are prophylactic antibiotics necessary for anterior nasal packing in epistaxis? Ann Emerg Med. 2015 Jan;65(1):109-11</ref>
	*ENT or ED follow-up in 2-3d for removal of nonbiodegradable packing		*ENT or ED follow-up in 2-3d for removal of nonbiodegradable packing