image by: Life Air Rescue
Administration of tranexamic acid (TXA) is integral part of the management for major trauma patients in the UK. It is deemed such an important aspect that its administration is used as a quality indicator to benchmark major trauma centres across the country. TXA is a medication that has raised a fair degree of controversy, mostly in the US, and whilst the current evidence base is not perfect (Ed – there is no such thing as a perfect evidence base outside of n=1 trials), we believe that until new evidence arives to the contrary then we should be giving it to our major trauma patients.
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2g IV bolus appears equally effective & safe.
Tranexamic acid can be administered safely to a wide
spectrum of patients with traumatic bleeding and should not be
restricted to the most severely injured.
Review of 3 major studies: Crash-2, Crash-3 and MATTERs.
Everyone knows about the CRASH-2 trial... It doesn’t seem like it desperately needs a new blog post, but I think that understanding this trial is important when trying to interpret the results of the newer CRASH-3 or WOMAN trials, and other TXA research that is on the horizon. So let’s review CRASH-2.
Why the early use of TXA should be strongly considered for any patient requiring blood products for trauma-related hemorrhage.
TXA was associated with decreased blood
product used, shorter hospital LOS, and
shorter ICU LOS, but the reduction was not
TXA is a generic drug that’s been around for decades, and in fact is sold over-the-counter in Europe and Japan for heavy menses. Delivered via IV to trauma patients, it’s been found to be lifesaving, with no dangerous side effects. It has the potential to save thousands of lives a year across the United States. And yet, very few EMS systems have incorporated it into their protocols.
In patients with massive bleeding from trauma or post-partum hemorrhage, giving TXA as soon as bleeding is suspected, reduces mortality from bleeding.
TXA can be administered safely in the prehospital setting to patients who have traumatic injuries and demonstrate hemodynamic instability.
The use of tranexamic acid(or TXA) has become widespread in the case of major trauma and bleeding and post partum haemorrhage. This time we discuss a recent paper that asks us if giving it within 3 hours is enough, or whether we need to be even more specific regarding its urgency of administration in order to save lives from bleeding.
Bottom Line For Emergency Physicians: Give intravenous TXA in trauma with confirmed or suspected major hemorrhage. Earlier treatment is better, and use 3 hours after injury may not be effective and may increase harm. Consider topical TXA for epistaxis or minor bleeding from dental extractions or lacerations. Epistaxis: Cotton pledget soaked in the injectable form of TXA (500 mg in 5 mL) is inserted into affected nostril. TXA mouthwash can be used for bleeding after dental procedures. If the mouthwash is not available, a paste can be made by crushing 3 TXA tablets and mixing with small aliquots of sterile water, and applying to sites of minor bleeding, such as dental extraction sites,
CRASH-2 randomized more than 20,000 patients to TXA infusion or placebo. In that trial, a small overall mortality difference was observed— all-cause mortality at four weeks post-injury was 14.5 percent in those treated with TXA compared to 16.0 percent of those treated with placebo.
TXA is a medication that has raised a fair degree of controversy, mostly in the US, and whilst the current evidence base is not perfect (Ed – there is no such thing as a perfect evidence base outside of n=1 trials), we believe that until new evidence arives to the contrary then we should be giving it to our major trauma patients.
In this retrospective observational study, the addition of tranexamic acid (TXA) to blood component based
resuscitation following combat injury showed improvement in measures of coagulopathy and survival, a benefit that
was most prominent in those patients requiring massive transfusion.
The absolute risk reduction in mortality with the use of TXA in trauma patients is very small. Neither did it reduce the amount of blood products administered. However, TXA is unlikely to cause harm and hence will continue to be part of practice in the management of the bleeding trauma patient.