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Three Part Question

In [adult patients with spontaneous epistaxis] do we need to [routinely test coagulation] to [rule out coagulation abnormalities]

Clinical Scenario

A 64 year old male presents with epistaxis. Your usual approach is to attain haemostasis, check for hypertension and coagulopathy. As you prepare to gain IV access and take blood you wonder whether there is any evidence to show that checking the clotting is warranted.

Search Strategy

Ovid MEDLINE(R) 1948 to March Week 4 2011. EMBASE via the NHS Evidence ‘Health Information Resources’ date of searching 31/03/2011. The Cochrane Library March 2011


Medline:[Exp epistaxis/] AND [exp International normalized ratio/ OR exp Prothrombin time/ OR exp Partial Thromboplastin Time/ OR exp Blood Clotting Test/ ] LIMIT to english language and humans

EMBASE:[epistaxis.ti] AND [exp International normalized ratio/ OR exp Prothrombin time/ OR exp Partial Thromboplastin Time/ OR exp Blood Clotting Test/ ] LIMIT to english language and humans

Cochrane: Epistaxis [mesh] 87 records none relevant

Search Outcome

63 papers were identified from Medline and an additional 19 from Embase. 3 were of sufficient quality for inclusion.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Jackson et al, 1988, USA	75 consecutive patients referred to one of the two authors after initial evaluation and treatment failure by primary care physicians	Observational	To identify underlying factors associated with active refractory epistaxis	Only patients with liver disease or treated with vitamin K antagonists had abnormal coagulation	Small numbers Does not indicate how many patients had abnormal coagulation
Thaha et al, 2000, UK	121 patients admitted with epistaxis between January and December 1998 who had coagulation studies performed	Observational	Cause of abnormal coagulation	10 patients had abnormal coagulation and all were taking warfarin	Small numbers
Awan et al, 2008, Pakistan	108 patients aged >14 years with epistaxis, requiring admission between January 2002 and December 2005	Observational	To identify groups of patients likely to present with coagulation abnormalities	10 patients had abnormal coagulation of which, 6 patients receiving anticoagulant treatment, 2 had chronic active hepatitis, 1 had liver cancer and 1 had haemophilia	Small numbers Different patient population to the UK

Comment(s)

All studies have shown that in patients presenting with epistaxis, all those with abnormal coagulation have clear reasons for this identified in the medical history. All studies were of good quality but the number of patients with abnormal coagulation were small.

Clinical Bottom Line

Adult patients presenting to the ED with epistaxis only need to have coagulation studies performed if the history indicates a potential cause of coagulopathy

Level of Evidence

Level 2 - Studies considered were neither 1 or 3.

References

1. Jackson KR, Jackson RT. Factors Associated With Active, Refractory Epistaxis Arch Otolaryngol Head Neck Surg 1988;114:862-865.
2. Thaha MA, Nilssen EL, Holland S et al. Routine coagulation screening in the management of emergency admission for epistaxis – is it necessary? The Journal of Laryngology and Otology 2000; Vol. 114, pp. 38–40
3. Awan MS, Iqbal M, Imam SZ. Epistaxis: when are coagulation studies justified? EMJ 2008; 25: 156-157