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Rosario E, Sharma E, Patel A, Guvensen G, Ashroff R, McClenaghan F, Hariri A, Joseph J. Use of tranexamic acid-soaked NasoPore® in the emergency department, to reduce epistaxis admissions. Clin Otolaryngol 2023; 48:909-914. [PMID: 37614122 DOI: 10.1111/coa.14093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 07/25/2023] [Accepted: 08/03/2023] [Indexed: 08/25/2023]
Abstract
OBJECTIVES The aim of this study was to assess the efficacy of a new emergency department (ED) intervention for the management of non-traumatic, anterior epistaxis in adult patients, aiming to reduce epistaxis admissions. DESIGN A new epistaxis pathway was introduced for use by ED practitioners. This was disseminated in ED through an educational campaign by the ear, nose and throat team. A tranexamic acid (500 mg/5 mL)-soaked NasoPore® packing step was introduced for epistaxis which did not terminate following 10 min of simple first aid. The pathway was utilised for adult patients presenting with non-traumatic, anterior epistaxis. Pre- and post-implementation periods were defined, and all adults attending ED with non-traumatic, anterior epistaxis were included. Pre- and post-implementation epistaxis treatment interventions, admission rates and re-attendance rates were recorded by retrospective audit and compared. RESULTS In the post-implementation group, epistaxis admissions were 51.7% (p < .05) lower than in the pre-implementation group, as a proportion of the total number attending ED with epistaxis during these periods. CONCLUSIONS The significant reduction in epistaxis admissions demonstrates that this ED intervention is beneficial for patient outcomes.
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Affiliation(s)
- Eleanor Rosario
- Department of Otolaryngology, University College London Hospitals, UK
| | - Ekta Sharma
- Department of Otolaryngology, University College London Hospitals, UK
| | - Ankit Patel
- Department of Otolaryngology, University College London Hospitals, UK
| | | | - Rizal Ashroff
- Accident & Emergency Department, University College London Hospitals, UK
| | - Fiona McClenaghan
- Department of Otolaryngology, University College London Hospitals, UK
| | - Ahmad Hariri
- Department of Otolaryngology, University College London Hospitals, UK
| | - Jonathan Joseph
- Department of Otolaryngology, University College London Hospitals, UK
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Hughes JM, Teh BM, Hart CJ, Gibbs HH, Aung AK. Risk factors and management outcomes in epistaxis: a tertiary centre experience. ANZ J Surg 2023; 93:555-560. [PMID: 36539988 DOI: 10.1111/ans.18179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 11/19/2022] [Accepted: 11/20/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Risk factors and outcomes associated with severe epistaxis are not well understood. This study explores the associations between epistaxis severity, comorbidities, use of antiplatelets or anticoagulants and management outcomes. METHODS This is a retrospective cross-sectional study of all epistaxis cases presenting to the emergency department at a tertiary academic hospital from January 2016 to December 2019. Epistaxis severity was defined as mild (no intervention), moderate (required cautery and/or packing) and severe (clinical instability with reversal products, surgical or radiological intervention). Univariable and multivariable regression analyses were undertaken, with risk factors and management outcomes analysed according to severity. RESULTS A total of 543 patients with epistaxis (54.2% male, mean age 74.4 ± 15.7 years) were included in this study, with 14.7% (80) having severe epistaxis. Of these presentations 216 (39.8%) were on antiplatelets, while 207 (38.1%) were on anticoagulants. In univariate analyses, clopidogrel use, hereditary haemorrhagic telangiectasia (HHT), haematological malignancy, bleeding disorders and chronic liver disease (CLD) were associated with moderate to severe epistaxis (P < 0.05), while the use of rivaroxaban was inversely associated severity (P = 0.002). Only HHT, haematological malignancy and CLD remained significant in multivariate models. Cautery as first-line management was infrequently utilized while anticoagulation was frequently withheld. A longer length of stay (1.1 days vs. 4.3 days; P < 0.001) and higher 2-week readmission rates (2.2% vs. 12.5%; P < 0.001) were noted with severe epistaxis compared with mild presentations. CONCLUSION Epistaxis severity is associated with certain clinical conditions and poor outcomes. Despite recommended guidelines, variations in first-line management were evident.
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Affiliation(s)
- Jed M Hughes
- Department of ENT, Head Neck Surgery, Austin Health, Melbourne, Victoria, Australia
| | - Bing Mei Teh
- Department of ENT, Head Neck Surgery, Austin Health, Melbourne, Victoria, Australia
- Department of Otolaryngology, Head and Neck Surgery, Monash Health; Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Cameron J Hart
- Department of ENT, Head Neck Surgery, Austin Health, Melbourne, Victoria, Australia
| | - Harry H Gibbs
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of General Medicine, Alfred Hospital, Melbourne, Victoria, Australia
| | - Ar Kar Aung
- Department of General Medicine, Alfred Hospital, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Cathcart RA, Williams R, Swift AC. Epistaxis. CONTEMPORARY RHINOLOGY: SCIENCE AND PRACTICE 2023:511-524. [DOI: 10.1007/978-3-031-28690-2_39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Nosulya EV, Miroshnichenko SA, Luchsheva YV, Aleksanyan TA, Ogorodnikov DS. [Epidemiology and modern methods of treatment of non-traumatic nosebleeds]. Vestn Otorinolaringol 2023; 88:63-68. [PMID: 37970772 DOI: 10.17116/otorino20238805163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
Abstract
Data on the detection incidence of nosebleeds (NBs) of non-traumatic origin in the population show considerable variability in statistical indicators, and NBs treatment and consequences depend on the localization of hemorrhage source, the volume of blood loss, patient's general condition, the presence and nature of comorbid pathology and a number of other factors. There are some differences in the choice of NBs treatment options, evaluation of their clinical and economic efficiency, which indicates the need to analyze and systematize the results of such studies. OBJECTIVE To analyze data on prevalence and current treatment approaches of non-traumatic nosebleeds. MATERIAL AND METHODS The search for publications (articles and related abstracts) on the subject of the study, presented in the PubMed database, has been conducted. The choice of material was made according to the following key words: non-traumatic nosebleeds, causes, incidence, methods of stopping nosebleeds. RESULTS The literature data show a significant prevalence of NBs in the population, their potential hazard to the life of patient and the importance of clinical and demographic characteristics of persons for determining treatment tactics in each case. In practical terms, primary and secondary NBs should be distinguished. In case of primary NB, the use of coagulation and nasal packing is recommended after determining the place of bleeding. In secondary NB it is necessary to establish its cause in order to assess risk factors and apply appropriate topical or systemic drug therapy. The so-called difficult (difficult-to-treat) NBs deserve special attention. As a rule, these cases involve bleeding from the posterior parts of nose. The analysis of publications shows a high (90%) efficacy of surgical interventions, used as first-line treatment. Effectiveness of embolization in such cases was 75% and of anterior/posterior nasal packing was 62%. CONCLUSION The literature data show a significant prevalence of nosebleeds in the population and their potential hazard to the life of patient. The existing differences in the assessments of treatment options for this pathology, their clinical and economic efficiency are the basis for further research, in particular, to clarify the causes of nosebleeds' occurrence and recurrence, the impact of treatment methods on quality of patients' life.
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Affiliation(s)
- E V Nosulya
- Sverzhevsky Research Institute of Clinical Otorhinolaryngology Moscow Department of Healthcare, Moscow, Russia
| | - S A Miroshnichenko
- Sverzhevsky Research Institute of Clinical Otorhinolaryngology Moscow Department of Healthcare, Moscow, Russia
| | - Yu V Luchsheva
- Sverzhevsky Research Institute of Clinical Otorhinolaryngology Moscow Department of Healthcare, Moscow, Russia
| | - T A Aleksanyan
- Sverzhevsky Research Institute of Clinical Otorhinolaryngology Moscow Department of Healthcare, Moscow, Russia
| | - D S Ogorodnikov
- Pirogov Russian National Research Medical University of the Ministry of Health of the Russian Federation, Moscow, Russia
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Jimenez-Martin J, Las Heras K, Etxabide A, Uranga J, de la Caba K, Guerrero P, Igartua M, Santos-Vizcaino E, Hernandez RM. Green hemostatic sponge-like scaffold composed of soy protein and chitin for the treatment of epistaxis. Mater Today Bio 2022; 15:100273. [PMID: 35572855 PMCID: PMC9097720 DOI: 10.1016/j.mtbio.2022.100273] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 04/25/2022] [Accepted: 04/26/2022] [Indexed: 12/03/2022] Open
Abstract
Epistaxis is one of the most common otorhinolaryngology emergencies worldwide. Although there are currently several treatments available, they present several disadvantages. This, in addition to the increasing social need of being environmentally respectful, led us to investigate whether a sponge-like scaffold (SP–CH) produced from natural by-products of the food industry — soy protein and β-chitin — can be employed as a nasal pack for the treatment of epistaxis. To evaluate the potential of our material as a nasal pack, it was compared with two of the most commonly used nasal packs in the clinic: a basic gauze and the gold standard Merocel®. Our SP-CH presented great physicochemical and mechanical properties, lost weight in aqueous medium, and could even partially degrade when incubated in blood. It was shown to be both biocompatible and hemocompatible in vitro, clearing up any doubt about its safety. It showed increased blood clotting capacity in vitro, as well as increased capacity to bind both red blood cells and platelets, compared to the standard gauze and Merocel®. Finally, a rat-tail amputation model revealed that our SP-CH could even reduce bleeding time in vivo. This work, carried out from a circular economy approach, demonstrates that a green strategy can be followed to manufacture nasal packs using valorized by-products of the food industry, with equal or even better hemostatic properties than the gold standard in the clinic.
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Affiliation(s)
- Jon Jimenez-Martin
- NanoBioCel Research Group, Laboratory of Pharmaceutics, School of Pharmacy, University of the Basque Country (UPV/EHU), Paseo de La Universidad 7, 01006 Vitoria Gasteiz, Spain
| | - Kevin Las Heras
- NanoBioCel Research Group, Laboratory of Pharmaceutics, School of Pharmacy, University of the Basque Country (UPV/EHU), Paseo de La Universidad 7, 01006 Vitoria Gasteiz, Spain
- Bioaraba, NanoBioCel Research Group, Vitoria Gasteiz, Spain
| | - Alaitz Etxabide
- BIOMAT Research Group, University of the Basque Country (UPV/EHU), Escuela de Ingeniería de Gipuzkoa, Plaza de Europa 1, 20018 Donostia-San Sebastián, Spain
| | - Jone Uranga
- BIOMAT Research Group, University of the Basque Country (UPV/EHU), Escuela de Ingeniería de Gipuzkoa, Plaza de Europa 1, 20018 Donostia-San Sebastián, Spain
| | - Koro de la Caba
- BIOMAT Research Group, University of the Basque Country (UPV/EHU), Escuela de Ingeniería de Gipuzkoa, Plaza de Europa 1, 20018 Donostia-San Sebastián, Spain
- BCMaterials, Basque Center for Materials, Applications and Nanostructures, UPV/EHU Science Park, 48940, Leioa, Spain
| | - Pedro Guerrero
- BIOMAT Research Group, University of the Basque Country (UPV/EHU), Escuela de Ingeniería de Gipuzkoa, Plaza de Europa 1, 20018 Donostia-San Sebastián, Spain
- BCMaterials, Basque Center for Materials, Applications and Nanostructures, UPV/EHU Science Park, 48940, Leioa, Spain
- Proteinmat Materials SL, Avenida de Tolosa 72, 20018 Donostia-San Sebastian, Spain
| | - Manoli Igartua
- NanoBioCel Research Group, Laboratory of Pharmaceutics, School of Pharmacy, University of the Basque Country (UPV/EHU), Paseo de La Universidad 7, 01006 Vitoria Gasteiz, Spain
- Biomedical Research Networking Centre in Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Institute of Health Carlos III, Madrid, Spain
- Bioaraba, NanoBioCel Research Group, Vitoria Gasteiz, Spain
| | - Edorta Santos-Vizcaino
- NanoBioCel Research Group, Laboratory of Pharmaceutics, School of Pharmacy, University of the Basque Country (UPV/EHU), Paseo de La Universidad 7, 01006 Vitoria Gasteiz, Spain
- Biomedical Research Networking Centre in Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Institute of Health Carlos III, Madrid, Spain
- Bioaraba, NanoBioCel Research Group, Vitoria Gasteiz, Spain
- Corresponding author. NanoBioCel Research Group, Laboratory of Pharmaceutics, School of Pharmacy, University of the Basque Country (UPV/EHU), Paseo de la Universidad 7, 01006 Vitoria Gasteiz, Spain.
| | - Rosa Maria Hernandez
- NanoBioCel Research Group, Laboratory of Pharmaceutics, School of Pharmacy, University of the Basque Country (UPV/EHU), Paseo de La Universidad 7, 01006 Vitoria Gasteiz, Spain
- Biomedical Research Networking Centre in Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Institute of Health Carlos III, Madrid, Spain
- Bioaraba, NanoBioCel Research Group, Vitoria Gasteiz, Spain
- Corresponding author. NanoBioCel Research Group, Laboratory of Pharmaceutics, School of Pharmacy, University of the Basque Country (UPV/EHU), Paseo de la Universidad 7, 01006 Vitoria Gasteiz, Spain.
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Thangavelu K, Köhnlein S, Eivazi B, Gurschi M, Stuck BA, Geisthoff U. [Epistaxis-overview and current aspects]. HNO 2021; 69:931-942. [PMID: 34643746 DOI: 10.1007/s00106-021-01110-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2021] [Indexed: 11/27/2022]
Abstract
Nosebleeds (epistaxis) are usually minor. Medical intervention is only necessary in about 6% of cases. The source of bleeding is frequently located in the anterior region of the nose (Kiesselbach's plexus). The estimated lifetime prevalence of epistaxis is 60%. Diffuse epistaxis is often a manifestation of systemic disease. Epistaxis is the leading symptom of Rendu-Osler-Weber disease (hereditary hemorrhagic telangiectasia, HHT). If intervention is required, the first-choice of treatment is bidigital compression for several minutes. Common therapeutic measures include local hemostasis using electrocoagulation or chemical agents, e.g., silver nitrate. Resorbable anterior nasal tampons or tampons with a smooth surface are also frequently employed. In case of failed surgical closure of the sphenopalatine artery, angiographic embolization is the method of choice.
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Affiliation(s)
- Kruthika Thangavelu
- Klinik für Hals‑, Nasen- und Ohrenheilkunde, Universitätsklinikum Gießen und Marburg GmbH, Philipps-Universität Marburg, Baldingerstraße, 35043, Marburg, Deutschland.
| | - Sabine Köhnlein
- Klinik für Hals‑, Nasen- und Ohrenheilkunde, Universitätsklinikum Gießen und Marburg GmbH, Philipps-Universität Marburg, Baldingerstraße, 35043, Marburg, Deutschland
| | - Behfar Eivazi
- Klinik für Hals‑, Nasen- und Ohrenheilkunde, Universitätsklinikum Gießen und Marburg GmbH, Philipps-Universität Marburg, Baldingerstraße, 35043, Marburg, Deutschland
- MED-HNO, Schwerpunktpraxis für HNO-Heilkunde, Kopf-Hals-Chirurgie und Plastische Operationen am Alice Hospital Darmstadt, Darmstadt, Deutschland
| | - Mariana Gurschi
- Klinik für Neuroradiologie, Universitätsklinikum Gießen und Marburg GmbH, Philipps-Universität Marburg, Marburg, Deutschland
| | - Boris A Stuck
- Klinik für Hals‑, Nasen- und Ohrenheilkunde, Universitätsklinikum Gießen und Marburg GmbH, Philipps-Universität Marburg, Baldingerstraße, 35043, Marburg, Deutschland
| | - Urban Geisthoff
- Klinik für Hals‑, Nasen- und Ohrenheilkunde, Universitätsklinikum Gießen und Marburg GmbH, Philipps-Universität Marburg, Baldingerstraße, 35043, Marburg, Deutschland
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Smith ME, Swords C, Rocke JPJ, Walker A, Bryan JE, Milinis K, Mathew RG, Jones GH, McLaren O, Hutson K, Slovick A, Hopkins C, Harries PG, Heward E, Shakeel M, Gomati A, Bance M, Lancaster J, Gaskell P, Smyth C, Dorris C, Kelly A, McCrory D, Bhatt YM, Jama GM, Morgan M, Perkins V, Spraggs P, Khosla S, Takwoingi Y, Gopala‐Krishnan S, Strachan D, Omakobia E, Puvanendran M, Myuran T, Rennie C, Devabalan Y, Cardozo A, Tse A, McRae D, Burgan OT, Reddy E, Wright B, Kara N, Ivy A, Williams R, Walkden A, Quraishi M, Stobbs N, Chatzimichalis M, Elston E, Khemani S, Liu A, Kirkland P, Vasanthan R, Miah M, Lee K, Mclarnon C, Williams MR, Okonkwo O, Mughal Z, Karagama Y, Xie C, De M, Amlani A, Jassar P, Cao H, Patil S, Philpott C, Meghji S, Das S, Cole S, Vijendren A, Ally M, Kothari P, Schechter E, Ranganathan B, Advani R, Toma S, Haymes A, Shakir A, Yap D, Costello R, Evans L, Chisholm E, Ojha S, Spielmann P, Steven R, Supriya M, Mathew E, Masood A, Dewhurst S, Ward V, Haigh T, Patiar S, Nemeth Z, Terry R, Vithlani R, Bowyer D, et alSmith ME, Swords C, Rocke JPJ, Walker A, Bryan JE, Milinis K, Mathew RG, Jones GH, McLaren O, Hutson K, Slovick A, Hopkins C, Harries PG, Heward E, Shakeel M, Gomati A, Bance M, Lancaster J, Gaskell P, Smyth C, Dorris C, Kelly A, McCrory D, Bhatt YM, Jama GM, Morgan M, Perkins V, Spraggs P, Khosla S, Takwoingi Y, Gopala‐Krishnan S, Strachan D, Omakobia E, Puvanendran M, Myuran T, Rennie C, Devabalan Y, Cardozo A, Tse A, McRae D, Burgan OT, Reddy E, Wright B, Kara N, Ivy A, Williams R, Walkden A, Quraishi M, Stobbs N, Chatzimichalis M, Elston E, Khemani S, Liu A, Kirkland P, Vasanthan R, Miah M, Lee K, Mclarnon C, Williams MR, Okonkwo O, Mughal Z, Karagama Y, Xie C, De M, Amlani A, Jassar P, Cao H, Patil S, Philpott C, Meghji S, Das S, Cole S, Vijendren A, Ally M, Kothari P, Schechter E, Ranganathan B, Advani R, Toma S, Haymes A, Shakir A, Yap D, Costello R, Evans L, Chisholm E, Ojha S, Spielmann P, Steven R, Supriya M, Mathew E, Masood A, Dewhurst S, Ward V, Haigh T, Patiar S, Nemeth Z, Terry R, Vithlani R, Bowyer D, Yang D, Monksfield P, Muzaffar J, Siddiq A, Whittaker JD, Ramakrishnan Y, Vakharia N, Cain A, Cooper F, Izzat S, Nair D, Tan S, Daudia A, Gilchrist J, Tan N, Kim M, Singh V, Hallett E, Ray J, Yu B, DeCarpentier J, Chandrasekar B, Bhimrao S, Eastwood M, Sunkaraneni VS, Patel J, Moore A, Shetty P, Mawby T, Shelton F, Jindal M, Yao A, Geyer M, Lowe E, Jones H, Ghasemi AA, Trinidade A, Hardy A, Little S, Munroe‐Gray T, Bennett A, Li L, Khalid‐Raja M, McNally G, Thomas G, Elmorsy M, Williams C, Zammit M, Seymour K, Warner E, Potter C, Easto R, Shaida A, Forde CT, Karamchandani D, Gill C, Syed I, Walker D, Stewart K, Simmons M, Abou‐Foul AK, Bathala S, Emerson H, Almeyda J, Leadon M, Fahmy F, Kaleva AI, Moorthy R, Bates J, Wasson J, Selwyn A, Daultrey C, Patel S, Siau D, Sawant R, Moore P, Ali F. Admission avoidance in acute epistaxis: A prospective national audit during the initial peak of the COVID‐19 pandemic. Clin Otolaryngol 2021; 46:577-586. [DOI: 10.1111/coa.13716] [Show More Authors] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 11/30/2020] [Accepted: 12/20/2020] [Indexed: 01/16/2023]
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Milinis K, Swords C, Hardman JC, Slovick A, Hutson K, Kuhn I, Smith ME. Dissolvable intranasal haemostatic agents for acute epistaxis: A systematic review and meta-analysis. Clin Otolaryngol 2021; 46:485-493. [PMID: 33453137 DOI: 10.1111/coa.13717] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 12/14/2020] [Accepted: 12/26/2020] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Nasal packing is the mainstay of epistaxis management; however, packs cause patient discomfort and can lead to hospital admission. Absorbable haemostats provide clotting factors or act as a substrate to stimulate clotting and represent a potential treatment alternative. A systematic review was performed to evaluate the efficacy of topical haemostats in the management of epistaxis. METHODS A systematic literature search of 7 databases was performed. Only eligible randomised controlled trials (RCTs) and observational studies were included. The primary outcome was short-term haemostatic success (<7 days). Secondary outcomes included long-term haemostatic control (no rebleeding 7-30 days), patient discomfort and adverse effects. Meta-analysis was performed where possible. RESULTS Of 2249 records identified, 12 were included in the qualitative synthesis and 4 RCTs were included in meta-analysis. The following haemostats were reported: gelatin-thrombin matrix (n = 8), aerosolised/gel tranexamic acid (n = 1), cellulose agents (n = 2) and fibrin sealants (n = 1). Studies involving tranexamic acid on removable delivery devices (eg, pledgets) were excluded. There was heterogeneity in outcome measures and inclusion criteria (coagulopathies/anticoagulants were excluded in 3 RCTs and 2 observational studies). The short-term haemostatic success varied between studies (13.9% to 100%). No significant post-procedural complications were reported. The meta-analysis favoured absorbable haemostatic agent versus packing (risk ratio 1.20; 95% confidence interval 1.05 to 1.37; P = .007). The risk of bias across all studies was moderate to high. CONCLUSIONS The evidence suggests haemostatic agents are effective at managing acute epistaxis when compared with nasal packing. More data are required before recommendations can be made regarding management in patients on anticoagulants.
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Affiliation(s)
| | - Chloe Swords
- Ear, Nose and Throat Department, Addenbrooke's Hospital, Cambridge, UK
| | - John C Hardman
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - Anna Slovick
- Ear, Nose and Throat Department, Barts Health NHS Trust, London, UK
| | - Kristian Hutson
- Ear, Nose and Throat Department, Addenbrooke's Hospital, Cambridge, UK
| | - Isla Kuhn
- School of Medicine, University of Cambridge, Cambridge, UK
| | - Matthew E Smith
- Ear, Nose and Throat Department, Addenbrooke's Hospital, Cambridge, UK
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