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Routine coagulation screening in the

management of emergency admission for
epistaxis - Is it necessary?

Article in The Journal of Laryngology & Otology February 2000

DOI: 10.1258/0022215001903861 Source: PubMed

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The Journal of Laryngology and Otology
January 2000, Vol. 114, pp. 3840

Routine coagulation screening in the management of

emergency admission for epistaxis is it necessary?
M. A. Thaha, M.B., B.S., E. L. K. Nilssen, F.C.S. (orl) S.A., F.R.C.S. (orl), D.L.O.,
S. Holland, B.Sc., M.B. C.H.B., G. Love, P. S. White, F.R.A.C.S., F.R.C.S.(Ed)

Abstract
The role of routine coagulation studies in the management of patients suffering from epistaxis is unclear.
In an attempt to address this issue the case notes of all emergency admissions for epistaxis to a large
Scottish teaching hospital were retrospectively reviewed over a one-year period. One hundred and forty
patients (63 male, 77 female) were admitted between January and December 1998. The patients who had
coagulation studies were identi ed and their results analysed. A total of 121 patients (86.4 per cent) had
coagulation studies performed. Of these, 10 (8.3 per cent) had abnormal results and all were taking
warfarin or a combination of warfarin and aspirin. No other coagulation abnormalities were identi ed.
This study supports the view that there does not appear to be a role for routine coagulation studies in
patients admitted with epistaxis. The investigation for potential haemostatic disorders should be
performed when clinically indicated and, if necessary, in consultation with the haematology service.
Key words: Epistaxis; Blood coagulation tests; Haemostasis

Introduction Materials and methods

Epistaxis remains the most common reason for The study took the form of a retrospective case sheet
emergency admission to ENT wards.1 In over 80 review of patients admitted to hospital for acute
per cent of cases no cause for the epistaxis is epistaxis during a one-year period from January
identied.2 ,3 The role or routine coagulation studies 1998 to December 1998 in a teaching hospital ENT
department. All those patients who had coagulation
in the management of patients without obvious
studies (PT/APTT) performed were identied and
indications for investigation is unclear. There is a the results of these tests evaluated. The platelet
paucity of information in the recent literature with count for each patient was also analysed, as this is
regard to this aspect of epistaxis management. part of the full blood count requested on all patients
A decade ago this issue was addressed in two admitted with epistaxis. Patients with factors putting
articles dealing with epistaxis and the authors them at risk of abnormal bleeding were also
suggested that routine coagulation studies were of identied and analysed. The PT in patients taking
little value in the absence of rm indications.3,4
Despite these ndings, coagulation studies continue
to be routinely ordered either as part of depart-
mental policy or by junior staff, who are often the
rst members of the ENT team to be involved in the
emergency care of these patients.
As it is policy in our unit that all patients with
severe epistaxis have prothrombin time (PT) and
activated partial thromboplastin time (APTT)
tested,5 the aim of this study was to determine
what percentage of patients admitted with epistaxis
had routine coagulation studies performed, what Fig. 1
The anticoagulant profile of patients admitted for the
percentage were found to be abnormal, and in which emergency treatment of epistaxis (n.=.121 expressed as
patient groups abnormalities were detected. percentage)

From the Department of Otolaryngology Head & Neck Surgery, Ninewells Hospital, Dundee, UK.
Accepted for publication: 8 October 1999.

38
routine coagulation screening in the management of emergency admission for epistaxis is it necessary? 39
TABLE I
costing coagulation studies per test (pt/aptt)
Direct labour costs 1.17
Equipment depreciation/running costs 0.21
Reaction tubes 0.09
Indirect labour/equipment costs 0.52
Test reagents 0.45
Daytime requests (9am5pm) Total cost = 2.44
Total for PT & APTT 4.88
Our-of-hours requests:
Additional cost (estimation) = 2.76 per test
Additional cost (estimation) = 5.20 per PT + APTT
Total for PT & APTT after- hours 10.40
warfarin was, for the purpose for this study,
considered abnormal if the result fell outside the
acceptable therapeutic range for the condition
requiring treatment.
In collaboration with the laboratory service of
Ninewells Hospital, Dundee, a cost analysis was
performed to identify the costs of performing these
tests during ofce hours, as well as for after-hours
requests.
Results
The patient records of 183 admissions (140 patients)
were analysed. There were 63 male and 77 female
patients with an age range of 993 years. The mean
age was 67, with a standard deviation of 19 years.
A total of 121 patients (86.4 per cent) had a
coagulation screen performed on admission. There
were 10 abnormal coagulation studies, which repre-
sents 8.3 per cent of the tests performed. All the
abnormal results were found in patients taking
warfarin or those on a combination of warfarin and
aspirin. Of those taking warfarin, nine (31 per cent)
had a PT outside the upper limit of the therapeutic
range. None of these patients required any ther-
apeutic intervention other than temporarily
withholding warfarin. The only abnormal platelet
counts found were in two patients known to be
suffering from myelodysplastic disorders. Both had
severe thrombocytopenia.
Figure 1 shows the patient medication prole with
regard to potential haemostatic dysfunction. The
results of the local cost analysis are illustrated in
Table I. The cost of requesting a daytime coagula-
tion screen is estimated to be 4.88. For out-of-hours
requests this rises to 10.40.
The readmission rate was 23.4 per cent. This
unexpected nding is being evaluated further, but is
at least partly explained by a group of patients with
hereditary haemorrhagic telangiectasia (HHT)
under the ENT departments care.
Four patients with HHT were responsible for 17
admissions during the period under review. To
prevent any possible skewing of the results by
repeated inclusion of patients with normal coagula-
tion studies, only individual patient results, and not
the individual admission results, were analysed to
produce the ndings of the study.
Discussion
Epistaxis is a common problem and those patients
who fail to settle with rst-aid measures implemen-
ted by their primary care physicians are usually
referred to hospital for further management, many
being referred on to the ENT service. Requests for
coagulation screens in this group of patients can be
highly variable. Few would dispute the need to
evaluate the haemoglobin level in patients with
signicant epistaxis, but what of routine coagulation
studies? Do they have a role (at extra expense to the
health service) and do they aid patient management?
The primary haemostatic response to bleeding is
an interaction between the blood vessel and the
circulating platelets. The vessel usually goes into
spasm and the platelets aggregate, forming a plug to
stem the blood ow. The secondary response is the
coagulation cascade, which is activated and leads to
the formation of a brin clot.6 It is this part of the
haemostatic system that is usually tested with
coagulation studies. The routine coagulation studies
performed are the PT (prothrombin time), which
evaluates the extrinsic pathway, and the APTT
(activated partial thromboplastin time), which
reects the activity of the intrinsic coagulation
pathway.7
The majority of epistaxis is due to local events in
the nose and not usually to dysfunction of the
haemostatic system. Our study supports the ndings
of previous investigators, who suggest that routine
coagulation studies are not indicated.3,4 and that
haematological studies should be requested in a
targeted rather than an indiscriminate manner. The
cost implications for the health service of routine
coagulation studies are signicant, as illustrated in
Table I. If one accepts that 99 patients in our study
did not have a specic indication for coagulation
studies, the potential cost saving here would have
been between 483.12 (during hours) and 1029.60
(out of hours), depending on the time of request.
Unfortunately, it proved impractical to collect data
about whether requests were made out of hours or
not. A recent study from this department looking at
current practice in Scotland with regard to coagula-
tion screening requests suggest that up to 30 per cent
of consultants and 50 per cent of junior staff request
these tests as a routine.8 If one were to extrapolate
the potential savings that could be achieved by not
requesting routine coagulation screens, this could
represent a signicant sum of money for the health
service in Scotland.
The most common inherited bleeding disorder is
von Willebrands disease, with a prevalence of 70 per
1 000 000 in the UK.9 Studies looking for cases of
von Willebrands disease report rates anywhere
between 0.82 per cent for non-specic screening to
5.6 per cent in patients with recurrent spontaneous
epistaxis.10 Because of the heterogeneous nature of
the disease, based on the pattern of genetic
inheritance and its milder forms of presentation,
routine coagulation screens will not necessarily
detect the condition in this form.1 0 If the rationale
for routine haemostatic investigations is to detect the
40
patients who present with this condition, the most
appropriate tests would include a more complete
haemostatic work-up, including bleeding time and
assays for Factor VIII and von Willebrand factor,
among others. This would signicantly increase both
cost and workload if applied in a non-targeted
manner.
In conclusion, only those patients with recurrent or
persistent bleeding dispute adequate medical ther-
apy, patients on anticoagulant medication, or those
having possible underlying bleeding diatheses based
on either history or examination, should be eval-
uated further. The investigations subsequently
chosen should also reect a sound understanding of
haemostatic function, so that they may be appro-
priate and relevant, and it is here that the role of the
haematologist is invaluable. If this practice were to
be followed then a signicant saving could be made
by the health service.
Acknowledgement
Special thanks to Mr Ken Kennedy, Chief Biomedi-
cal Scientist, Acting Laboratory Manager, Ninewells
Hospital, Dundee, for his assistance in costing the
coagulation studies.
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Address for correspondence:
Mr E. Nilssen,
Department of Otolaryngology, Head & Neck Surgery,
Ninewells Hospital,
Dundee DD1 9SY.