What to do if nasal packing with tranexamic acid (TXA) fails to control bleeding?

Management of Failed Tranexamic Acid Nasal Packing

If nasal packing with tranexamic acid fails to control epistaxis, proceed immediately to nasal cautery after anesthetizing the bleeding site, or if the bleeding source cannot be identified or cautery fails, escalate to formal nasal packing with resorbable materials. 1

Immediate Next Steps

Step 1: Identify the Bleeding Source

• Remove any blood clot and perform anterior rhinoscopy to visualize the bleeding site, as identification of the source is critical for guiding further management 1
• If anterior rhinoscopy fails to identify the source, proceed immediately to nasal endoscopy to examine the nasal cavity and nasopharynx, particularly for posterior bleeding sites 1, 2
• The American Academy of Otolaryngology-Head and Neck Surgery specifically recommends endoscopy when epistaxis is difficult to control 2

Step 2: Cauterize the Bleeding Site

• Cautery is better tolerated and more effective than packing regardless of the method used 1
• Anesthetize the bleeding site with topical lidocaine or tetracaine applied via spray or cotton pledgets 1
• Restrict cautery application only to the active or suspected bleeding site(s) to minimize risk of septal perforation 1
• Bipolar electrocautery is preferred over chemical cautery (such as silver nitrate), as it is less painful with faster healing and more effective 1

Step 3: Formal Nasal Packing if Cautery Fails

• If bleeding continues despite cautery or the bleeding site cannot be identified, proceed to formal anterior nasal packing 1
• Use resorbable packing materials (such as gelfoam, oxidized cellulose, or other absorbable materials) rather than non-resorbable packing 1
• This is particularly important if the patient has a suspected bleeding disorder or is on anticoagulation/antiplatelet medications 1

Special Considerations for Severe or Life-Threatening Bleeding

Hemodynamic Assessment

• If the patient shows signs of hemodynamic instability (hypotension, tachycardia, syncope), this represents life-threatening bleeding requiring immediate resuscitation 2
• Establish IV access and initiate fluid resuscitation while simultaneously controlling bleeding 2
• Consider blood transfusion for severe blood loss, though first-line treatments should be attempted first unless bleeding is truly life-threatening 2

Advanced Interventions

• For persistent bleeding despite packing and cautery, consider arterial ligation or embolization 2
• Endoscopic sphenopalatine artery ligation may be required for posterior bleeding sources 1

Critical Pitfalls to Avoid

• Do not delay endoscopy when standard measures fail, as it is essential for identifying posterior or difficult-to-visualize bleeding sources 2
• Avoid bilateral cautery or use it selectively and cautiously to minimize risk of septal perforation 1
• Do not reverse anticoagulation or withdraw antiplatelet medications unless bleeding is truly life-threatening and cannot be controlled by other means 2
• First-line and advanced treatments (cautery, packing, ligation/embolization) should be exhausted before considering anticoagulation reversal 2

Evidence Context

The evidence shows that while topical TXA may be effective for initial epistaxis control in some studies 3, 4, a large 2021 UK multicenter randomized controlled trial found no significant benefit of topical TXA over placebo in reducing the need for nasal packing 5. This suggests that when TXA-soaked packing fails, the TXA itself may not be providing additional hemostatic benefit beyond the mechanical tamponade effect, making escalation to definitive interventions (cautery or formal packing) the appropriate next step 1.