Page 26 - JSOM Summer 2019

Case Series hemostatic matrix, FloSeal. This final step achieved hemosta-
sis. The patient was sent to a tertiary center in Baltimore at
Patient 1 the request of her insurance company and kept overnight for
A 62-year-old woman who was taking warfarin presented with observation. Follow-up past this transfer was not available.
profuse epistaxis from her left nostril. She tried pressure to the
area for 1 hour and it did not resolve. On arrival to the ED, Discussion
per our nursing triage protocol, she was roomed with stable
vitals and direct pressure was applied to the nose. The patient It is challenging to isolate the many variables that go into each
blew out several formed clots, and two sprays of oxymetazo- epistaxis patient, but we have presented three difficult-to-treat
line was used to the left nostril. Her international normalized cases where ATXA played an adjunctive role. The first case
ratio was 2.78. The patient continued to bleed heavily despite is seen fairly often in the ED—epistaxis from an elevated in-
these interventions. Fresh-frozen plasma (FFP) was not readily ternational normalized ratio. The second case of epistaxis
available. The patient was unable to tolerate nasal packing from a nasal mass is rare but could be considered a proxy
attempts due to anxiety over the procedure. ENT consult was for nosebleeds seen in oncologic emergencies. The third case
not readily available, and given the ongoing hemorrhage, we represents a more common scenario of an unknown source for
decided to try ATXA at 100mg/mL. Five 1mL aliquots were the epistaxis.
applied to the left nostril, 3-5 seconds apart (500mg total),
and hemostasis was achieved within 1 minute. As the patient TXA has been studied in varying forms—tablets, gel, paste,
became calmer, she allowed us to place an 8cm Merocel sponge topical liquid, and intravenously. Oral TXA has been approved
to pack the left nostril. There was no further major bleeding, by the US Food and Drug Administration for heavy menstrual
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and after observation for 2 hours in the ED, the patient was bleeding since 2009. Recent emergency medicine literature
discharged. She returned the next day for a wound check and has focused on application then removal of a TXA-soaked
had no complaints or further bleeding. Four days later, ENT pledget for epistaxis. However, in our experience, many pa-
consult removed the packing with no noted complications. tients, due to apprehension of rebleeding on discharge and the
difficulty of obtaining quick follow-up care, still require nasal
Patient 2 packing or the use of a hemostatic matrix agent. As a response
A 22-year-old man with a known but undifferentiated sinus to these realities, we sought out a modified technique using an
mass arrived with significant epistaxis from his right nostril. atomizer to deliver TXA. This technique allows the patient to
He was treated with conventional therapy (direct pressure, inhale a fine spray of TXA that we believe has better surface
Merocel packing) for 2.5 hours in our ED and continued to area coverage directly to the most common source of epistaxis,
12
bleed. The patient’s blood pressure dropped below 90mmHg Kiesselbach plexus, located on the anterior nasal septum. Us-
and he became diaphoretic, nauseous, and lightheaded, requir- ing a spray also allows the provider to maintain a controlled,
ing 1L of normal saline and an antiemetic. At 4 hours into stepwise treatment approach and maximize patient comfort.
his ED course, with his blood pressure stabilized and after Nasal packing and/or hemostatic matrix agents are then used
consulting with ENT, the decision was made to use ATXA at as a final option. Nasal packing is removable and readily avail-
100mg/mL. Three 1mL aliquots were applied to the right nos- able in the ED and is often the most used treatment modality.
tril, 3–5 seconds apart (300mg total), and his bleeding slowed Hemostatic matrix agents remain costly ($100 to $500 per
down significantly. An 8cm Merocel sponge was applied, but single use), are not readily available, and in a lower resource
the patient continued to ooze blood around this packing ap- setting have an “all or nothing” risk—that is, it’s great when
proximately 30 minutes after it was inserted; a final method, it works, but if it fails then there is no room for nasal pack-
FloSeal, a hemostatic matrix agent, was used. This achieved ing and the hardened matrix cannot be easily removed. From
hemostasis and the patient was discharged home 2 hours later. our experience, the ideal treatment may involve developing a
His sinus mass was formally biopsied by ENT 3 days later and single product that combines topical TXA with nasal packing.
was found to be a benign polyp.
ATXA has three potential military applications. First, as
Patient 3 outlined in the three cases, ATXA may be useful in treating
A 67-year-old woman presented to the ED for her fourth ep- patients taking blood thinners who do not respond to direct
isode in 3 weeks of bilateral epistaxis. On each of the three pressure but where immediate nasal packing is not feasible.
prior visits, she had nasal packing placed and ENT follow-up For medical personnel on humanitarian operations or sit-
within 3 days. Within 6 hours of her packing being removed uations involving civilian casualties, atomizing TXA could
in the office, each time she had a subsequent bleed that caused prove to be an excellent adjunct. Second, in facial trauma with
her to come back to our ED. This particular time, she arrived bleeding that cannot be controlled by direct pressure or nasal
covered in blood, anxious, and tachypneic. She had vital signs packing, ATXA could aid in hemostasis. Given the concerns
done in triage and was placed in a room, and direct external for basilar skull and open facial fractures sustained in combat
pressure was applied. The nursing staff had the patient blow wounds, the use of ATXA in this setting would need signifi-
out several clots and applied two sprays of oxymetazoline to cant research and testing.
each nostril. Given the severity of the bleed and the patient’s
rapid, shallow breathing, nasal packing was not feasible. The third, most intriguing application is administering ATXA
ATXA was administered to the right nostril where bleeding in massive hemorrhage—both in tactical and prolonged field
was more pronounced. Three 1mL aliquots at 100mg/mL care settings. Schauer et al reported that only 19% of trauma
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were applied (300mg total), and this slowed down the bleed- cases from Afghanistan received IV TXA. In 2018, Vu et al
14
ing enough to both calm the patient and then allow an 8cm reviewed the possibility of using intramuscular TXA. TXA
Merocel sponge to be inserted. One hour later, her right nostril comes in 1000mg/10mL vials. Per TCCC guidelines, 1g in
began to rebleed slightly, so the decision was made to use a 100mL of normal saline or lactated Ringer’s within 3 hours of

24 | JSOM Volume 19, Edition 2 / Summer 2019