Finger on the Pulse: TXA

We’re back for yet another exciting edition. This week we’ll be focusing on:

Tranexamic acid (TXA) and its unique applications

Ever ordered TXA? Want to?9_21 pic

Here are some unique applications to try:

  • Epistaxis
  • Oral Bleeds
  • Hyphema

We’ll use epistaxis to highlight some of TXA’s advantages:

1) Application: Easy. Use IV solution (500mg/5ml), pour it on a pledget and insert, wait for hemostasis (~5min), remove pledget and observe.

2) Efficacy: With regards to epistaxis, the results for TXA vs. anterior packing look good:

In a study done by Zahed et al. 2013 in AJEM, which compared TXA to anterior packing in ED patients, they found that in the TXA group:

  • Bleeding was arrested much faster
  • Patients were discharged faster
  • Rebleeding occurred less often
  • Patients were more satisfied    

Their results are below:

Results: Within 10 minutes of treatment, bleedings were arrested in 71% of the patients in the tranexamic acid group, compared with 31.2% in the anterior nasal packing group (odds ratio, 2.28; 95% confidence interval, 1.68-3.09; P < .001). In addition, 95.3% in the tranexamic acid group were discharged in 2 hours or less vs. 6.4% in the anterior nasal packing group (P < .001). Rebleeding was reported in 4.7% and 11% of patients during first 24 hours in the tranexamic acid and the anterior nasal packing groups, respectively (P = .128). Satisfaction rate was higher in the tranexamic acid compared with the anterior nasal packing group (8.5 ± 1.7 vs 4.4 ± 1.8, P b .001).

Technique: The difference in technique between the two groups was: In the TXA group, a 15-cm piece of cotton pledget soaked in injectable form of tranexamic acid (500 mg in 5 mL) was inserted in the nostril of the bleeding side. It was removed after bleeding arrest was determined by examining the blood-soaked pledgets and the oropharynx. In the anterior nasal packing group, usual shrinkage, with a cotton pledget soaked in epinephrine (1:100000) + lidocaine (2%) for 10 minutes, and packing, with several cotton pledgets covered with tetracycline, were performed in the nostril of the bleeding side. Nasal packing was removed after 3 days.

The difference between techniques is compelling. Who would want a pledget or rhino rocket in their nose for 3 days? Patients who were in the TXA group had their packing removed after bleeding had stopped while those with the classic anterior packing went home with packing in their nose for 3 days. Reason alone to give TXA a try.

3) Cost effective. At our shop, a vial of TXA costs ~$50.

4) Relatively safe: Because it’s topical, many studies have demonstrated its lack of systemic effects and shown its safe use in a wide variety of patients (see references below).


If you’re interested and want to dive a little deeper, go to REBELEM.

RebelEM is FOAM site dedicated to evidence-based clinical topics. It’s got a great cast of EM Docs who contribute to the site and some fantastic reviews on a variety of topics.

They have an excellent review on TXA at:

http://rebelem.com/topical-tranexamic-acid-epistaxis-oral-bleeds/

Or see the original article:

Zahed, Reza, Payman Moharamzadeh, Saeid Alizadeharasi, Asghar Ghasemi, and Morteza Saeedi. 2013. A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial. The American journal of emergency medicine, no. 9 (July 30).


References

Carter, G. et al. International Journal of Oral and Maxillofacial Surgery , Volume 32 , Issue 5 , 504 – 507

Ker K, Beecher D, Roberts I. Topical application of tranexamic acid for the reduction of bleeding. Cochrane Database of Systematic Reviews 2013, Issue 7. Art. No.: CD010562. DOI: 10.1002/14651858.CD010562.pub2.

Nuvvula, Sivakumar, Kumar Raja Gaddam, and Rekhalakshmi Kamatham. 2014. Efficacy of tranexamic acid mouthwash as an alternative for factor replacement in gingival bleeding during dental scaling in cases of hemophilia: A randomized clinical trial. Contemporary clinical dentistry, no. 1. doi:10.4103/0976-237X.128663. http://www.ncbi.nlm.nih.gov/pubmed/24808695.

Tranexamic acid mouthwash — A prospective randomized study of a 2-day regimen vs 5-day regimen to prevent postoperative bleeding in anticoagulated patients requiring dental extractions

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