We do not need to routinely test coagulation in adult patients with epistaxis
Date First Published:
December 19, 2010
Last Updated:
June 30, 2011
Report by:
David Hodgson, Core Trainee (3) Emergency Medicine (Mersey School of Emergency Medicine, UK)
Search checked by:
Peter Burdett-Smith, Mersey School of Emergency Medicine, UK
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
Search Details:
<br><br>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<br><br>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<br><br>Cochrane: Epistaxis [mesh] 87 records none relevant
Outcome:
63 papers were identified from Medline and an additional 19 from Embase. 3 were of sufficient quality for inclusion.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Factors Associated With Active, Refractory Epistaxis Jackson KR, Jackson RT. 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 |
| Routine coagulation screening in the management of emergency admission for epistaxis – is it necessary? Thaha MA, Nilssen EL, Holland S 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 |
| Epistaxis: when are coagulation studies justified? Awan MS, Iqbal M, Imam SZ. 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 |
Author Commentary:
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.
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:
- Jackson KR, Jackson RT. . Factors Associated With Active, Refractory Epistaxis
- Thaha MA, Nilssen EL, Holland S et al. . Routine coagulation screening in the management of emergency admission for epistaxis – is it necessary?
- Awan MS, Iqbal M, Imam SZ.. Epistaxis: when are coagulation studies justified?