Page 25 - JSOM Summer 2019

Use of Atomized Intranasal Tranexamic Acid
as an Adjunctive Therapy in Difficult-to-Treat Epistaxis

1
Debjeet Sarkar, MD, FAAFP *; Jesus Martinez, BS 2

ABSTRACT
There is a growing body of literature on the safe, effective use studied is an intranasal, topical application of a TXA-soaked
of tranexamic acid (TXA) for hemostasis in a variety of clin- pledget. Emergency providers have extended this tech-
5,6
ical settings. We present a case series of three patients with nique to epistaxis cases seen with direct oral anticoagulants
difficult-to-treat epistaxis where standard treatment methods ( DOACs) such as rivaroxaban. In this report, we describe
7,8
were not effective. Using atomized intranasal TXA (ATXA) as three cases using a novel mode of delivery, atomized intranasal
part of a stepwise treatment approach, we were able to achieve TXA (ATXA), in patients where conventional epistaxis man-
hemostasis and manage all three cases independently, and we agement was not effective.
did so without major complications in our emergency depart-
ment (ED). Given recent literature showing the underuse of As we used ATXA, the parallel to intranasal ketamine (INK)
TXA in combat casualties, ATXA, if formulated and delivered use became apparent, and we realized there could be a role in
properly, may be of benefit for epistaxis and other significant the military setting. 9,10 While the pharmacology is vastly differ-
hemorrhage cases. Further work must be done to elucidate the ent for the two medications, INK use highlights the concept of
mechanism of action, specific dose, delivery method, use indi- a lightweight, easy-to-use, multipurpose medication that gives
cations, and safety profile of ATXA. medical personnel treatment options to adjust to a variety of
possible clinical scenarios. By outlining our early experiences
Keywords: epistaxis; atomized; tranexamic acid; TXA; atom- with ATXA in this case series, we hope to begin the discus-
ized intranasal TXA; intranasal sion on how it can be used not just for epistaxis but also for
broader applications.

Introduction Methods
Epistaxis a common complaint in the ED, and it has been es- Each patient in this report gave written consent for standard
timated that 60% of the general population has experienced emergency care treatment (required for all patients in our ED)
at least one episode of epistaxis. In the United States, epistaxis followed by individual, verbal informed consent before using
accounts for 1 in every 200 ED visits. Although most cases ATXA. No institutional review board approval was obtained
are mild and self-limiting, a proportion can require emergent because all three cases required emergent treatment and had
medical attention due to hypotension, emesis, and airway not responded to conventional, available therapies. The use
1-3
compromise from respiratory distress and occlusion. Cur- of ATXA in each of these difficult-to-treat epistaxis cases was
rently, there are no published, evidence-based guidelines for discussed and reviewed over the phone by the corresponding
epistaxis management (the American Academy of Otolaryn- author with the on-call ear/nose/throat (ENT) consultant as
gology is due to publish its algorithm in 2019; the American well as our in-house hospital pharmacist, before the decision
College of Emergency Physicians has a position paper from to use it, to ensure no absolute contraindications. A stepwise
4
2009 ), but common practice uses multiple modalities. Direct epistaxis algorithm was designed by the lead author and later
pressure, nose clips, cauterization, and commercially available approved by our ED medical director and lead ENT consultant
hemostatic packing (Merocel, Medtronic; Rapid Rhino, Smith based on these cases and on a review of the evidence-based
& Nephew; Rhino Rocket, Shippert) are the most common literature (Appendix 1). All cases were treated in our ED by
methods used. Hemostatic absorbable products (Surgicel, the lead author and our team of nurses at Howard County
Ethicon; Gelfoam Baxter), hemostatic matrix agents (FloSeal, General Hospital in Columbia. The atomizer device used was
Baxter; SurgiFlo, Ethicon), arterial embolization, and ligation MAD Nasal (Teleflex; Figure 1a), which generates a mist with
are more advanced methods used to treat epistaxis. particles ~30-100μm in size. Our facility is a primary stroke
center, has no trauma designation, and sees approximately
In difficult-to-treat epistaxis cases, where these methods fail 65,000 adult patients per year. Our facility does not have sur-
or are not readily available, there is still a need to find afford- gical subspecialty backup in-house, and the closest tertiary re-
able and accessible adjuncts. One such option that has been ferral center is 25 miles away in Baltimore.
*Correspondence to Debjeet Sarkar, MD, Howard County General Hospital, Department of Emergency Medicine, 5755 Cedar Lane, Columbia,
MD 21044 or dsarkar4@jhmi.edu
2
1 MAJ Sarkar, MC, USA (IRR) is affiliated with the Department of Emergency Medicine, Howard County General Hospital, Columbia, MD. Mr
Martinez is affiliated with Georgetown University School of Medicine, Washington, DC.
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