Authors: Mark Winstanley, Andy Neill, Dave McCreary, Nikki Abela, Liz Herrieven, Mark Lyttle / Codes: CP3, EP3, SLO1, SLO10, SLO9, TP1 / Published: 02/12/2019


Andy Neill

Dave McCreary

Clinical Question:

Is TXA better than merocel in epistaxis


Evaluating Effectiveness of Nasal Compression With Tranexamic Acid Compared With Simple Nasal Compression and Merocel Packing: A Randomized Controlled Trial.


Akkan, July 2019, Annals EM


– TXA is making a move to become the one drug to rule them all in EM. We have covered this before somewhere (though I couldn’t find the link at time of writing). And i have used this several times with success. Though to be fair most of what we do for epistaxis already works and a lot of it may be the simple natural history of epistaxis. 

– now we have an RCT of TXA with simple packing versus one of the old favourites – the merocel. Now I think in most EDs i’ve worked the inflatable balloon model (named after a large african horned animal) is probaby the first choice. Though we did have an ENT surgeon on the podcast express his extreme distaste for such balloons. 


– non blinded single centre RCT in Turkey done in just 3 months

– primary bleeding was stopping of bleeding at 15 mins which seems fair and appropriate

– powered for a 15% improvement 

– excluded the anticoagulated (which is most unfortunate)

– randimsed to one of 3 groups

1) external pressure with some saline sprayed in the nose as a placebo

2) TXA in the nose and external pressure

3) merocel in the nose for 24 hrs


– Mean age 60

– 90% stopped bleeding at 15 mins in the TXA and merocel groups v 70% in the simple compression group

– worth noting that they only expected a 30% success rate when doing their power calculation so these were likely very minor bleeds


– once again TXA seems a reasonable option in the management of epistaxis. Though i would simply add TXA into all the other options we have, all of which seem to be effective in the vasty majority of cases. The bigger issue in EM I think is the limited technical skill set that many EM practitioners have. Don’t expect TXA to save you if you haven’t done the basics of spending some time watching the ENT docs manage epistaxis as they have some real pearls to share. 


Dr Liz Herrieven @Lizjl78
Dr Nikki Abela @NikkiAbela


Dr Mark Lyttle @mdlyttle
Dr Mark Winstanley @markwinstanley4


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