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Playfair A, Dillon B, Futterer C, Riviello RJ. Topical Tranexamic Acid to Control Vaginal Laceration Bleeding after Sexual Assault. J Emerg Med 2024; 67:e65-e68. [PMID: 38825529 DOI: 10.1016/j.jemermed.2024.03.009] [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: 07/17/2023] [Revised: 01/12/2024] [Accepted: 03/06/2024] [Indexed: 06/04/2024]
Abstract
BACKGROUND Sexual assault survivors may sustain vaginal trauma that requires intervention in the emergency department, or operating room. CASE REPORT We describe the case of a 16-year-old female who was referred to the emergency department for evaluation of continued bleeding from a vaginal laceration following sexual assault 38 h prior. The bleeding limited the medical forensic medical examination, but she was hemodynamically stable. After the application of tranexamic acid (TXA)-soaked gauze, the patient's bleeding was controlled and the wound was able to be evaluated and the examination completed. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: To our knowledge, this is the first case in the literature that describes the use of topical TXA in a patient to achieve hemostasis in a vaginal laceration sustained from sexual violence.
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Affiliation(s)
- Ashtyn Playfair
- Methodist Hospital Specialty and Transplant Hospital, Forensic Nurse Program, San Antonio, Texas
| | | | - Carissa Futterer
- Methodist Hospital Specialty and Transplant Hospital, Forensic Nurse Program, San Antonio, Texas
| | - Ralph J Riviello
- Department of Emergency Medicine, UT Health San Antonio, San Antonio, Texas.
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2
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Alkazemi A, Kovacevic M, Dube K, Lauffenburger JC, Smith A, Malinowski S, Weinhouse GL. Effectiveness of Nebulized Tranexamic Acid in Patients with Moderate-to-Massive Hemoptysis at a Tertiary Academic Medical Center. J Aerosol Med Pulm Drug Deliv 2023; 36:309-315. [PMID: 37962861 DOI: 10.1089/jamp.2022.0038] [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: 11/15/2023] Open
Abstract
Introduction: The management of severe hemoptysis mainly consists of invasive interventional procedures, including angiographic bronchial artery embolization, various endobronchial interventions, and sometimes surgery. However, there are limited effective noninvasive medical therapies available. The objective of this analysis was to evaluate the effectiveness and safety of nebulized tranexamic acid (TXA) administration compared with conventional management in patients with hemoptysis. Methods: This Institutional Review Board-approved, single-center, retrospective matched cohort study was performed from January 1, 2018 to March 31, 2021. Electronic health record data were used to identify all adult inpatients with hemoptysis (International Classification of Diseases, Tenth Revision, code R04.2). All patients who received ≥1 dose of nebulized TXA were matched with up to five controls based on available severity criteria (hemoptysis severity, need for mechanical ventilation, and sequential organ failure assessment score at the time of hemoptysis diagnosis) with coarsened exact matching. The primary outcome was the need for invasive interventions for the management of hemoptysis. Secondary outcomes included time to hemoptysis resolution, duration of mechanical ventilation, hemoptysis recurrence, and hospital length of stay. Results: A total of 14 patients were treated with nebulized TXA; they were matched with 58 controls. Patients were 59.7% male, had a median age of 65.5 years, with airway disease (36.1%) being the major etiology of hemoptysis. There was no difference in the number of patients who required an invasive intervention between the TXA (35.7%) versus control group (56.9%), p = 0.344. Additionally, no difference was found in the time to hemoptysis resolution (p = 0.050), duration on mechanical ventilation (p = 0.128), hemoptysis recurrence (p = 1.000), or hospital length of stay (p = 0.139). Conclusions: In patients with hemoptysis, nebulized TXA may be considered as a noninvasive option for the management of hemoptysis. However, a larger analysis is warranted to determine the impact of nebulized TXA on invasive interventions for management.
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Affiliation(s)
- Afrah Alkazemi
- Department of Pharmacy Practice, College of Pharmacy, Kuwait University, Kuwait City, Kuwait
| | - Mary Kovacevic
- Department of Pharmacy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kevin Dube
- Department of Pharmacy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Julie C Lauffenburger
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Adam Smith
- Department of Respiratory Therapy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Stephen Malinowski
- Department of Respiratory Therapy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Gerald L Weinhouse
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Gopinath B, Mishra PR, Aggarwal P, Nayaka R, Naik SR, Kappagantu V, Shrimal P, Ramaswami A, Bhoi S, Jamshed N, Sinha TP, Ekka M, Kumar A. Nebulized vs IV Tranexamic Acid for Hemoptysis: A Pilot Randomized Controlled Trial. Chest 2023; 163:1176-1184. [PMID: 36410494 DOI: 10.1016/j.chest.2022.11.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 11/10/2022] [Accepted: 11/12/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Tranexamic acid (TA) is used to control bleeding in patients with hemoptysis. However, the effectiveness of the different routes of TA administration has not been studied. RESEARCH QUESTION Does the nebulized route of TA administration reduce the amount of hemoptysis compared with the IV route in patients presenting to the ED with hemoptysis? STUDY DESIGN AND METHODS This was a pragmatic, open-label, randomized, parallel, single-center, pilot trial of nebulized TA (500 mg tid) vs IV TA (500 mg tid) in adult patients presenting to the ED with active hemoptysis. The primary outcome was cessation of bleeding at 30 min. Secondary outcomes included amount of hemoptysis at 6, 12, and 24 h; interventional procedures; and side effects of TA. Patients who were hemodynamically unstable or requiring immediate interventional procedure or mechanical ventilation were excluded from the study. RESULTS Of the 55 patients in each arm, hemoptysis cessation at 30 min following TA administration was significantly higher in the nebulization arm (n = 40) compared with the IV arm (n = 28): χ2 (1, n = 110) = 5.55; P = .0019. Also, hemoptysis amount was reduced significantly in the nebulization arm at all time periods of observation (P value at 30 min = .011, at 6 h = .002, 12 h = .0008, and at 24 h = .005). Fewer patients in the nebulization arm required bronchial artery embolization (13 vs 21; P = .024) and thereby had higher discharge rates from the ED (67.92% vs 39.02%; P = .005). Two patients in the nebulization arm had asymptomatic bronchoconstriction that resolved after short-acting beta-agonist nebulization. No patient discharged from the ED underwent any interventional procedure or revisited the ED with rebleed during the 72 h follow-up period. INTERPRETATION Nebulized TA may be more efficacious than IV TA in reducing the amount of hemoptysis and need for ED interventional procedures. Future larger studies are needed to further explore the potential of nebulized TA compared with IV TA in patients with mild hemoptysis. CLINICAL TRIAL REGISTRATION Clinical Trials Registry-India; No.: CTRI/2019/05/019337; URL: http://ctri.nic.in/Clinicaltrials/advancesearchmain.php.
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Affiliation(s)
- Bharath Gopinath
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Prakash Ranjan Mishra
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India.
| | - Praveen Aggarwal
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Rakesh Nayaka
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Shivdas Rajaram Naik
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Vignan Kappagantu
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Prawal Shrimal
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Akshaya Ramaswami
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Sanjeev Bhoi
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Nayer Jamshed
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Tej Prakash Sinha
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Meera Ekka
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Akshay Kumar
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
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Cutshall DM, Inman BL, Myers M. Treatment of Massive Hemoptysis with Repeated Doses of Nebulized Tranexamic Acid. Cureus 2022; 14:e29625. [PMID: 36321025 PMCID: PMC9605738 DOI: 10.7759/cureus.29625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2022] [Indexed: 11/30/2022] Open
Abstract
When life-threatening hemoptysis occurs, it can be challenging to treat. We present a case of a 61-year-old female with massive hemoptysis treated with multiple doses of nebulized tranexamic acid (TXA). This treatment led to the resolution of respiratory distress and the improvement of hemoptysis. Ultimately, in cases of massive hemoptysis, repeated treatments with nebulized TXA may be a safe short-term option for symptom management prior to a more definitive therapy via bronchoscopy or bronchial arterial embolization.
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Patel S, Angelidis IK, Malsin ES, Smith S, Pawale A, Budd AN. Inhaled Tranexamic Acid for the Management of Hemoptysis in a Patient With Right and Left Ventricular Assist Devices: A Case Report. A A Pract 2022; 16:e01604. [PMID: 35917204 DOI: 10.1213/xaa.0000000000001604] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The use of mechanical circulatory support (MCS) devices continues to expand in cases of refractory cardiogenic shock. Bleeding is one of the most common complications associated with MCS, and management can be challenging due to need for systemic anticoagulation. Significant hemoptysis can be a devastating complication. We describe a case of a patient supported by a right ventricular assist device with an oxygenator and a left ventricular assist device who developed pulmonary hemorrhage that was successfully treated with nebulized tranexamic acid (TXA). Following a 5-day treatment course, bleeding resolved, no adverse side effects were noted, and systemic anticoagulation was resumed.
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Affiliation(s)
- Shamik Patel
- From the Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Department of Anesthesiology, Northwestern Medicine, Chicago, Illinois
| | - Ioannis K Angelidis
- Department of Anesthesiology
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois
| | - Elizabeth S Malsin
- From the Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Department of Pulmonary and Critical Care Medicine, Northwestern Medicine, Chicago, Illinois
| | - Sean Smith
- From the Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Department of Pulmonary and Critical Care Medicine, Northwestern Medicine, Chicago, Illinois
| | - Amit Pawale
- Department of Cardiac Surgery, Washington University, St. Louis, Missouri
| | - Ashley N Budd
- From the Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Department of Anesthesiology, Northwestern Medicine, Chicago, Illinois
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Cao A, Silverman J, Zahtz G, Smith LP. Use of nebulized tranexamic acid in adult and pediatric post-tonsillectomy hemorrhage. OTOLARYNGOLOGY CASE REPORTS 2022. [DOI: 10.1016/j.xocr.2022.100409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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7
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Tranexamic acid – A narrative review for the emergency medicine clinician. Am J Emerg Med 2022; 56:33-44. [DOI: 10.1016/j.ajem.2022.03.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 03/07/2022] [Accepted: 03/14/2022] [Indexed: 02/06/2023] Open
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Tranexamic Acid for the Treatment of Acute Gastrointestinal Bleeding in a Jehovah's Witness Patient on Apixaban and Dual Antiplatelet Therapy: A Case Report. Adv Emerg Nurs J 2022; 44:11-18. [PMID: 35089274 DOI: 10.1097/tme.0000000000000386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Life-threatening bleeding can be challenging to manage, especially in patients who reject allogeneic transfusions for religious or personal reasons. Tranexamic acid (TXA) has been successfully used to treat acute bleeding in multiple settings with varying severity, including trauma, women with postpartum hemorrhage, hemoptysis, and epistaxis, with minimal adverse effects. The purpose of this case report is to describe the use of TXA to aid in achieving hemostasis in a Jehovah's Witness patient on apixaban with a life-threatening gastrointestinal (GI) bleed. An 80-year-old female Jehovah's Witness patient on apixaban for lower extremity deep vein thrombosis presented to the emergency department with 8 hr of GI bleeding. On presentation, she was hemodynamically unstable, requiring a norepinephrine infusion. She refused any blood-derived products or anticoagulant reversal agents derived from human or animal products. One 1-g dose of intravenous TXA was given as a bolus for more than 10 min, followed by another 1-g dose for more than 8 hr. The patient achieved successful hemostasis allowing for further inpatient management and eventually was discharged from the hospital. This case describes a life-threatening GI bleed in a Jehovah's Witness patient who was successfully treated using TXA.
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Dermendjieva M, Gopalsami A, Glennon N, Torbati S. Nebulized Tranexamic Acid in Secondary Post-Tonsillectomy Hemorrhage: Case Series and Review of the Literature. Clin Pract Cases Emerg Med 2021; 5:1-7. [PMID: 34437029 PMCID: PMC8373187 DOI: 10.5811/cpcem.2021.5.52549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/24/2021] [Accepted: 05/28/2021] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Post-tonsillectomy hemorrhage is a serious postoperative complication, and its acute management can present a challenge for the emergency provider. Although various strategies have been proposed, guidance on the best approach for management of this condition in the emergency department (ED) setting remains limited. Anecdotal reports of the use of nebulized tranexamic acid (TXA) for management of tonsillar bleeding have emerged over the past two years. Two recently published case reports describe the successful use of nebulized TXA for stabilization of post-tonsillectomy hemorrhage in an adult and a pediatric patient. CASE SERIES Eight patients who presented to our ED with secondary post-tonsillectomy hemorrhage received nebulized TXA for hemostatic management. The most common TXA dose used was 500 milligrams, and all but one patient received a single dose of the medication in the ED. Hemostatic benefit was observed in six patients, with complete bleeding cessation observed in five cases. Interventions prior to nebulized TXA administration were attempted in three of the six patients and included ice water gargle, direct pressure with TXA-soaked gauze, and nebulized racemic epinephrine. All but one of the patients were taken to the operating room for definitive management after initial stabilization in the ED. CONCLUSION Nebulized TXA may offer a hemostatic benefit and aid in stabilization of tonsillectomy hemorrhage in the acute care setting, prior to definitive surgical intervention. Consideration of general principles of nebulization and aerosol particle size may be an important factor for drug delivery to the target tissue site.
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Affiliation(s)
- Mira Dermendjieva
- Cedars Sinai Medical Center, Department of Pharmacy Los Angeles, California
| | - Anand Gopalsami
- Cedars Sinai Medical Center, Department of Emergency Medicine, Los Angeles, California
| | - Nicole Glennon
- Cedars Sinai Medical Center, Department of Emergency Medicine, Los Angeles, California
| | - Sam Torbati
- Cedars Sinai Medical Center, Department of Emergency Medicine, Los Angeles, California
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Dempsey JM, Jones M, Bronner J, Greer C, Howington GT. Inhaled Tranexamic Acid for Massive Hemoptysis in the Setting of Oral Anticoagulation: A Case Report. Clin Pract Cases Emerg Med 2020; 4:572-575. [PMID: 33217275 PMCID: PMC7676782 DOI: 10.5811/cpcem.2020.7.48525] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 07/31/2020] [Indexed: 12/02/2022] Open
Abstract
Introduction We discuss a case of massive hemoptysis in the setting of a direct-acting oral anticoagulant (DOAC) successfully managed with nebulized tranexamic acid (TXA). Case Report Per the American College of Cardiology and the American Society of Hematology, it is recommended that significant bleeding associated with a DOAC be treated with either 4-factor prothrombin complex concentrate or andexanet alfa. However, our patient was at high risk for thrombotic complications given a recent pulmonary embolism. Conclusion We demonstrate that it is reasonable to trial nebulized TXA given its low cost, ease of administration, and safety profile. Additionally, this report discusses a unique dosing strategy and a previously unreported complication associated with nebulization of undiluted TXA.
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Affiliation(s)
- Jacqueline M Dempsey
- University of Kentucky HealthCare, Department of Pharmacy Services, Lexington, Kentucky
| | - Mandy Jones
- University of Kentucky, Department of Pharmacy Practice and Science, Lexington, Kentucky
| | - Jonathan Bronner
- University of Kentucky HealthCare, Department of Emergency Medicine, Lexington, Kentucky
| | - Connor Greer
- University of Kentucky HealthCare, Department of Emergency Medicine, Lexington, Kentucky
| | - Gavin T Howington
- University of Kentucky HealthCare, Department of Pharmacy Services, Lexington, Kentucky.,University of Kentucky, Department of Pharmacy Practice and Science, Lexington, Kentucky
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Prophylactic use of tranexamic acid for decreasing the blood loss in elective cesarean section: A placebo-controlled randomized clinical trial. J Gynecol Obstet Hum Reprod 2020; 50:101973. [PMID: 33221559 DOI: 10.1016/j.jogoh.2020.101973] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 10/29/2020] [Accepted: 11/03/2020] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Tranexamic acid is used as a known treatment of post-partum hemorrhage both in natural vaginal deliveries and cesarean sections, but its use in elective cesarean as a prophylactic measure to decrease the blood loss is not so common. OBJECTIVE This clinical trial evaluates the efficacy and safety of tranexamic acid in decreasing the bleeding in women undergoing elective cesarean section. METHOD 200 term singleton pregnant women who were scheduled for elective cesarean section were randomized to 2 groups and received a bolus of 1 gm tranexamic acid if body weight was <90 kg and 1.5 g if body weight was >90 kg diluted in 15 ml of 5% dextrose intravenously, or 5 ml of distilled water in 15 ml of 5% dextrose as placebo (before skin incision). Intra-operative and post-operative blood loss and hemoglobin levels were compared. RESULTS Tranexamic acid decreased the mean blood loss by 25.3 % in our studied women. Mean volume of intra-operative blood loss was 391.1 (±67.4) ml in tranexamic acid group and 523.8 (±153.4) ml in control group which was statistically significant lesser with a 132.7 ml difference. Rate of >1000 ml and >500 ml bleeding and need to blood transfusion were also statistically significant lower in tranexamic acid group., mean hemoglobin level was statistically significant lower in placebo group than tranexamic acid group (11.77 ± 0.50 versus 11.31 ± 0.56) 6 h after cesarean section. No adverse reaction was documented. CONCLUSION Prophylactic use of intravenous tranexamic acid decreases the blood loss safely in women undergoing elective cesarean section.
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Poppe M, Grimaldo F. A Case Report of Nebulized Tranexamic Acid for Post-tonsillectomy Hemorrhage in an Adult. Clin Pract Cases Emerg Med 2020; 4:443-445. [PMID: 32926708 PMCID: PMC7434284 DOI: 10.5811/cpcem.2020.6.47676] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 06/10/2020] [Indexed: 01/10/2023] Open
Abstract
Introduction Post-tonsillectomy hemorrhage is a potentially life-threatening, postoperative complication that is commonly encountered in the emergency department (ED). Case Report Herein, we describe the case of a 22-year-old male who presented to the ED with an active post-tonsillectomy hemorrhage. He rapidly became hypotensive and experienced an episode of syncope. Immediate interventions included intravenous fluids, emergency release blood and nebulized tranexamic acid (TXA). After completion of the nebulized TXA, the patient’s bleeding was controlled. Conclusion To our knowledge, this is the first case in the emergency medicine literature that describes the use of nebulized TXA in an adult to achieve hemostasis in post-tonsillectomy hemorrhage.
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Affiliation(s)
- Michael Poppe
- Naval Medical Center San Diego, Department of Emergency Medicine, San Diego, California
| | - Felipe Grimaldo
- Naval Medical Center San Diego, Department of Emergency Medicine, San Diego, California
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Alabdrabalnabi F, Alshahrani M, Ismail N. Nebulized tranexamic acid for recurring hemoptysis in critically ill patients: case series. Int J Emerg Med 2020; 13:45. [PMID: 32819268 PMCID: PMC7439666 DOI: 10.1186/s12245-020-00304-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 08/07/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Hemoptysis is a clinical condition encountered in the emergency department (ED) and must be managed and investigated urgently to maintain the patient's hemostasis. The management of hemoptysis depends on treating the underlying cause. Tranexamic acid (TXA) is an anti-fibrinolytic drug used to systemically control bleeding. There are a few studies available that investigate the use of nebulized tranexamic acid for hemoptysis with contradictory results. Our paper demonstrates three cases where patients presented with significant hemoptysis and had significant improvement in symptoms following the administration of nebulized tranexamic acid. The overall need for blood transfusion was reduced. RESULTS Three patients presented to the emergency room for evaluation of hemoptysis. All three patients had different underlying pathologies resulting in their hemoptysis and were monitored in the ICU. Initial conventional medical therapies including the correction of coagulopathy and discontinuing offending agents were utilized for treatment. After persistent symptoms, nebulized TXA at a dose of 500 mg three times a day was administered. The patients were all discharged from the hospital with improvement in their symptoms. CONCLUSION Tranexamic acid may be considered in the treatment of hemoptysis regardless of the underlying cause. This may be utilized pending further workup and investigation into the underlying source of the bleeding.
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Affiliation(s)
- Fatimah Alabdrabalnabi
- Imam Abdulrahman Bin Faisal University and King Fahad University hospital, Dammam, Saudi Arabia
| | - Mohammed Alshahrani
- Imam Abdulrahman Bin Faisal University and King Fahad University hospital, Dammam, Saudi Arabia
| | - Nadia Ismail
- Imam Abdulrahman Bin Faisal University and King Fahad University hospital, Dammam, Saudi Arabia
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Effects of Tranexamic Acid on Hemoptysis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Clin Drug Investig 2020; 40:789-797. [DOI: 10.1007/s40261-020-00946-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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15
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Pan CX, Palathra BC, Leo-To WF. Management of Respiratory Symptoms in Those with Serious Illness. Med Clin North Am 2020; 104:455-470. [PMID: 32312409 DOI: 10.1016/j.mcna.2019.12.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Respiratory symptoms are common in patients living with serious illness, both in cancer and nonmalignant conditions. Common symptoms include dyspnea (breathlessness), cough, malignant pleural effusions, airway secretions, and hemoptysis. Basic management of respiratory symptoms is within the scope of primary palliative care. There are pharmacologic and nonpharmacologic approaches to treating respiratory symptoms. This article provides clinicians with treatment approaches to these burdensome symptoms.
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Affiliation(s)
- Cynthia X Pan
- Division of Palliative Medicine and Geriatrics, Designated Institution Official of Graduate Medical Education, NewYork-Presbyterian Queens, 56-45 Main Street, Flushing, NY 11355, USA; Weill Cornell Medical College, New York, NY, USA.
| | - Brigit C Palathra
- Weill Cornell Medical College, New York, NY, USA; Hospice and Palliative Medicine Fellowship, Division of Palliative Medicine and Geriatrics, NewYork-Presbyterian Queens, 56-45 Main Street, Flushing, NY 11355, USA. https://twitter.com/bpalathra
| | - Wing Fun Leo-To
- NewYork-Presbyterian Queens, 56-45 Main Street, Flushing, NY 11355, USA; Affiliate Clinical Faculty, College of Pharmacy and Health Science, St John's University, Jamaica, NY, USA
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Lee J, Rhee CK, Kim SC, Kim YK, Kim HJ, Lee S, Cho SG, Lee JW. Use of intrapulmonary administration of thrombin in hematological malignancy patients with alveolar haemorrhage: A case series. Medicine (Baltimore) 2020; 99:e20284. [PMID: 32443373 PMCID: PMC7253869 DOI: 10.1097/md.0000000000020284] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Alveolar hemorrhage (AH) is characterized by the acute onset of alveolar bleeding and hypoxemia and can be fatal. Thrombin has been widely used to achieve coagulation and hemostasis. However, the efficacy of thrombin in patients with AH is unclear. Thus, this study aimed to evaluate the efficacy of thrombin administration in patients with hematological malignancy and AH. PATIENT CONCERNS AND DIAGNOSES This retrospective study included 15 hematological malignancy patients (8 men and 7 women; mean age 47.7 ± 17.3 years) with AH who were administered intrapulmonary thrombin between March 2013 and July 2018. INTERVENTIONS AND OUTCOMES All patients received bovine-origin thrombin (1000 IU/ml, Reyon Pharmaceutical Co., Ltd., Seoul, Korea) via a fiberoptic bronchoscope. A maximum of 15 ml of thrombin was injected via the working channel to control bleeding. The ability of thrombin to control bleeding was assessed. Additionally, the change in the PaO2/FiO2 (PF) ratio after intrapulmonary thrombin administration was evaluated. Intrapulmonary thrombin was administered a minimum of 3 days after starting mechanical ventilation in all patients, and it immediately controlled the active bleeding in 13 of 15 patients (86.7%). However, AH relapse was noted in 3 of the 13 patients (23.1%). The PF ratio improved in 10 of 15 patients (66.6%), and the mean PF ratio was significantly higher after thrombin administration than before administration (P = .03). No adverse thromboembolic complications or systemic adverse events were observed. CONCLUSION Thrombin administration was effective in controlling bleeding in hematological malignancy patients with AH. Intrapulmonary thrombin administration might be a good therapeutic option for treating AH.
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Affiliation(s)
- Jongmin Lee
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine
| | - Chin Kook Rhee
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine
| | - Seok Chan Kim
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine
| | - Young Kyoon Kim
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine
| | - Hee Je Kim
- Division of Hematology, Catholic Blood and Marrow Transplantation Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seok Lee
- Division of Hematology, Catholic Blood and Marrow Transplantation Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seok-Goo Cho
- Division of Hematology, Catholic Blood and Marrow Transplantation Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jong Wook Lee
- Division of Hematology, Catholic Blood and Marrow Transplantation Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Kathuria H, Hollingsworth HM, Vilvendhan R, Reardon C. Management of life-threatening hemoptysis. J Intensive Care 2020; 8:23. [PMID: 32280479 PMCID: PMC7132983 DOI: 10.1186/s40560-020-00441-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 03/09/2020] [Indexed: 12/14/2022] Open
Abstract
It is estimated that 5-14% of patients presenting with hemoptysis will have life-threatening hemoptysis, with a reported mortality rate between 9 and 38%. This manuscript provides a comprehensive literature review on life-threatening hemoptysis, including the etiology and mechanisms, initial stabilization, and management of patients. There is no consensus on the optimal diagnostic approach to life-threatening hemoptysis, so we present a practical approach to utilizing chest radiography, computed tomography, and bronchoscopy, alone or in combination, to localize the bleeding site depending on patient stability. The role of angiography and embolization as well as bronchoscopic and surgical techniques for the management of life-threatening hemoptysis is reviewed. Through case presentation and flow diagram, an overview is provided on how to systematically evaluate and treat the bronchial arteries, which are responsible for hemoptysis in 90% of cases. Treatment options for recurrent hemoptysis and definitive management are discussed, highlighting the role of bronchial artery embolization for recurrent hemoptysis.
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Affiliation(s)
- Hasmeena Kathuria
- 1The Pulmonary Center, Boston University School of Medicine, 72 E. Concord St R304, Boston, MA 02118 USA
| | - Helen M Hollingsworth
- 1The Pulmonary Center, Boston University School of Medicine, 72 E. Concord St R304, Boston, MA 02118 USA
| | - Rajendran Vilvendhan
- 2Interventional Radiology, Department of Radiology, Boston Medical Center, Boston, MA USA
| | - Christine Reardon
- 1The Pulmonary Center, Boston University School of Medicine, 72 E. Concord St R304, Boston, MA 02118 USA
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18
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Assadi T. Nebulized tranexamic acid for post-tonsillectomy hemorrhage in children: a promising game changer. Am J Emerg Med 2020; 38:1943. [PMID: 32024591 DOI: 10.1016/j.ajem.2020.01.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 01/23/2020] [Indexed: 10/25/2022] Open
Affiliation(s)
- Touraj Assadi
- Department of Emergency Medicine, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran.
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19
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Inhaled Tranexamic Acid As a Novel Treatment for Pulmonary Hemorrhage in Critically Ill Pediatric Patients: An Observational Study. Crit Care Explor 2020; 2:e0075. [PMID: 32166295 PMCID: PMC7063899 DOI: 10.1097/cce.0000000000000075] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Objectives: To describe the use of inhaled or endotracheally instilled tranexamic acid in critically ill pediatric patients for the treatment of pulmonary hemorrhage, which can be severe, life-threatening, and include potentially high-risk management procedures. Design: Retrospective observational study from 2011-2018 with patients followed until hospital discharge. Setting: Free-standing children’s hospital with an annual ICU volume of more than 3,500 yearly admissions. Patients: Pediatric patients, ages 0 to 18 years, admitted to an ICU and who received at least one dose of inhaled or endotracheally instilled tranexamic acid were included. Interventions: Inhaled or endotracheally instilled tranexamic acid. Measurements and Main Results: This study described the efficacy and adverse effects of patients who received inhaled or endotracheally instilled tranexamic acid. A total of 19 patients met inclusion criteria; median age was 72 months (11–187 mo), most patients were female (11, 58%), and almost half our patients (8, 42%) had congenital heart disease. Nine of 19 encounters (47%) had diffuse alveolar hemorrhage, four (21%) had pulmonary hemorrhage related to major aortopulmonary collateral arteries, two (11%) had mucosal airway bleeding, two (11%) were iatrogenic, one had a pulmonary embolism, and one patient did not have their etiology of pulmonary hemorrhage determined. Cessation of pulmonary hemorrhage was achieved in 18 of 19 patients (95%) with inhaled tranexamic acid with no major adverse events recorded. Conclusions and Relevance: We demonstrate that inhaled tranexamic acid may be safely used to treat pulmonary hemorrhage from varied etiologies in critically ill pediatric patients. Prospective studies are required in this vulnerable population to determine optimal dosing and delivery strategies, as well as to define any differential effect according to etiology.
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20
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Inhaled TXA for cases of massive hemoptysis. Am J Emerg Med 2020; 38:156-157. [DOI: 10.1016/j.ajem.2019.05.056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 05/29/2019] [Indexed: 11/22/2022] Open
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21
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Nebulized Tranexamic Acid for the Use of Epistaxis: A Case Report. J Emerg Med 2019; 58:110-112. [PMID: 31818611 DOI: 10.1016/j.jemermed.2019.10.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 10/14/2019] [Accepted: 10/27/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Tranexamic acid is an antifibrinolytic agent and functions as a competitive inhibitor of plasminogen activation, promoting hemostasis. Topical application of tranexamic acid for the control of epistaxis has been described in the literature, mainly through administration with gauze and packing. There is limited evidence for the use of tranexamic acid via alternative routes of administration such as nebulization. CASE REPORT We describe a patient who presented to the emergency department with epistaxis who was treated with nebulized tranexamic acid. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Our case provides an alternative treatment modality using nebulizing tranexamic acid to help manage epistaxis in patients that cannot be managed with topical antifibrinolytic therapy administered by other means.
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22
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Dhanani JA, Roberts J, Reade MC. Nebulized Tranexamic Acid Therapy for Hemoptysis Associated with Submassive Pulmonary Embolism. J Aerosol Med Pulm Drug Deliv 2019; 33:12-14. [PMID: 31161941 DOI: 10.1089/jamp.2019.1534] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Hemoptysis and pulmonary embolism (PE) are life-threatening pulmonary emergencies that, when present together, create a therapeutic conundrum. We present an illustrative case of a 65-year-old man with unprovoked submassive PE and moderate hemoptysis due to pulmonary infarction. Hemoptysis precluded systemic anticoagulation. Failing a conservative management strategy, we administered nebulized tranexamic acid. After four doses of nebulized tranexamic acid 500 mg, 6 hours apart, hemoptysis had ceased. Systemic anticoagulation with intravenous heparin was then successfully commenced 12 hours after the last episode of hemoptysis. The patient was weaned off high-flow nasal oxygen therapy over the course of the next 5 days with no hemoptysis recurrence. Noting the absence of trial evidence, but good pharmacological rationale and our positive experience, we suggest tranexamic acid is a useful noninvasive treatment option for the management of such conditions. Consent for this publication was obtained from the patient.
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Affiliation(s)
- Jayesh A Dhanani
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia.,Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Brisbane, Australia.,Burns, Trauma and Critical Care Research Centre, University of Queensland, Brisbane, Australia
| | - Jason Roberts
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia.,Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Brisbane, Australia.,Centre for Translational Anti-Infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Australia.,Department of Pharmacy, Royal Brisbane & Women's Hospital, Brisbane, Australia
| | - Michael C Reade
- Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Brisbane, Australia.,Burns, Trauma and Critical Care Research Centre, University of Queensland, Brisbane, Australia.,Joint Health Command, Australian Defence Force, Canberra, Australia
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23
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Bharath G, Mishra PR, Aggarwal P. Tranexamic Acid. Chest 2019; 155:1303-1304. [DOI: 10.1016/j.chest.2019.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 02/01/2019] [Indexed: 10/26/2022] Open
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24
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Wand O, Guber E, Guber A, Epstein Shochet G, Israeli-Shani L, Shitrit D. Inhaled Tranexamic Acid for Hemoptysis Treatment. Chest 2018; 154:1379-1384. [DOI: 10.1016/j.chest.2018.09.026] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 07/29/2018] [Accepted: 09/05/2018] [Indexed: 10/28/2022] Open
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25
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Berman S, Bucher J, Koyfman A, Long BJ. Emergent Complications of Rheumatoid Arthritis. J Emerg Med 2018; 55:647-658. [DOI: 10.1016/j.jemermed.2018.07.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 07/03/2018] [Accepted: 07/22/2018] [Indexed: 12/20/2022]
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26
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Schwarz W, Ruttan T, Bundick K. Nebulized Tranexamic Acid Use for Pediatric Secondary Post-Tonsillectomy Hemorrhage. Ann Emerg Med 2018; 73:269-271. [PMID: 30292524 DOI: 10.1016/j.annemergmed.2018.08.429] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Indexed: 12/16/2022]
Abstract
Post-tonsillectomy hemorrhage is a frequent occurrence in the emergency department, and management of potentially life-threatening and ongoing bleeding by the emergency physician is challenging. Limited evidence-based guidelines exist, and practice patterns vary widely. We administered nebulized tranexamic acid to achieve hemostasis in a pediatric patient with associated bleeding cessation prior to definitive operative management.
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Affiliation(s)
- Whitney Schwarz
- Dell Children's Medical Center, University of Texas at Austin Dell Medical School, Austin, TX.
| | - Timothy Ruttan
- Dell Children's Medical Center, University of Texas at Austin Dell Medical School, Austin, TX
| | - Kelly Bundick
- Dell Children's Medical Center, University of Texas at Austin Dell Medical School, Austin, TX
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