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Tranexamic Acid: Timing Matters!

Source: MedPage Today

Tranexamic Acid, more commonly known as TXA has been around for the better part of six decades. Surgery suites have had great successes with this pharmacological agent, but only recently has this drug begin to surface in the prehospital setting. TXA's newly adopted EMS acceptance is largely in part due to some great research over the past 10+ years. We will look at (2) such trials in brief summation here:

MATTERS (2012)

A retrospective review of military hospitals, a smaller sample size (896 patients) that look at patients receiving blood and separately those requiring massive transfusion protocol (MTP). The conclusion of this study really reinforced that the use of TXA with blood component-based resuscitation following combat injury results in improved measures of coagulopathy and survival, a benefit that is most prominent in patients requiring massive transfusion. Treatment with TXA should be implemented into clinical practice as part of a resuscitation strategy following severe wartime injury and hemorrhage.

CRASH-2 (2013)

A Randomized Controlled Trial (RCT) - these are the gold standard by the way. This looked at 20,000+ trauma patients across hundreds of hospitals. The patients were either demonstrating signs of hemorrhage or at risk for hemorrhage. This study showed that more favorable outcomes were possible with TXA administration via a reduction in overall mortality. EARLY administration of TXA was key, as those who received the drug after 3 hours from injury onset didn't really see or experience any benefits.

Some things to keep in mind about TXA and how the body works:

The body not only has to form clots via a coagulation pathway during internal/external trauma, but the body must also "clean up" and breakdown the clots when things have stabilized -- this is fibrinolysis. TXA's role is these processes is not to be a pro-coagulant, but yet an anti-fibrinolytic. TXA doesn't promote clotting, but its overarching goal is to prevent the breakdown of an already formed fibrin clot. TXA essentially allows the clot to stay active for a longer period of time to stop bleeding.

TXA side effects are usually minimal, but as expected it can increase the risk of thrombotic events like DVT/PE.... however, in acute trauma also weigh the risk/benefit profile -- more than likely with benefits will be victorious and prompt the administration.

The medication is safe for ALL ages.

Reserve its use for patients with evidence of / or / concern for blunt or penetrating traumatic injury (MVC w/ ejection, rollovers, fall > 20', many long bone fractures, post-partum hemorrhage, traumatic brain injuries)

Your patients will in most, but not all cases by hypotensive and tachycardic

Time since initial injury should be < 3 hours -- this is paramount!! Preferably within 60 minutes of onset.

Initial adult dose: 1g in 100ml of NSS over 10' -- given to fast can worsen hypotension if present. * (Dedicated line if possible)

Initial pedi (< 12 yo) dose: Mix 15mg/kg (max 1g) in 100 ml of NSS over 10'*

*Keep in mind your local protocols may vary slightly - the above just represents commonly accepted practices.

June 12, 2023

Author: Joshua Ishmael, MBA, MLS(ASCP)CM, NRP

Pass with PASS, LLC.

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