Tranexamic acid (TXA)

DOSING

2 grams slow IV/IO push within 3 hours of injury.

DISCUSSION

In the fall of 2020 the United States Department of Defense (DOD) Committee on Tactical Combat Casualty Care (CoTCCC) updated the Tactical Combat Casualty Care (TCCC) guidelines to specify TXA dosing of 2 grams slow IV/IO push.

Trauma involving life-threatening hemorrhage in the YK Delta, particularly when managed in village clinics, occurs in a context with substantial similarities to the military battlefield. Similarities include:

1. Limited (on nonexistant) blood supply.
2. Long transport times/distances.
3. Transport through a hostile environment (particularly in the winter).
4. High cognitive and physical task load on a limited number of care givers (such as two MedEvac crew members).

QUESTIONS and ANSWERS

The CoTCCC evidence review (as discussed by Drew et al) identified and answered a number of important questions:

1. Should a TBI Indication Be Added to the TXA Recommendations in the TCCC Guidelines and the Dose Increased to 2 Grams? YES
2. Is There a Need to Reinforce the Timely Administration of TXA When Indicated? YES
3. Is a Second Dose of TXA Needed to Improve Outcomes When Used for Bleeding Trauma Patients? NO
4. Is TXA Effective When Administered via the IM route to Bleeding Trauma Patients? NO
5. Is TXA Effective When Administered via the IO route to Bleeding Trauma Patients? YES
6. Can TXA Be Safely Given as a Slow (1-minute) IV Push Rather Than over 10 minutes? YES
7. Can TXA Be Given in the same IV/IO Line as Blood / Blood Products? YES
8. Should the Second Dose of TXA Be Administered If More Than 3 Hours Have Elapsed Since the Time of Wounding? NO
9. Is There a Need for a Second Dose of TXA to be Administered as Part of TCCC, given the Discussion of the Pharmacokinetics of TXA Mentioned Above? NO
10. Should the Dose of TXA be Modified in the Presence of Ongoing Hemorrhage? Not in the prehospital phase of care.
11. Can TXA Be Administered Through the Same Line as Hextend? YES
12. What Is the Current State of Evidence that TXA Causes an Increase in the Risk of Deep Venous Thrombosis and Pulmonary Embolism? Evidence is conflicting, but leaning toward no increased risk of VTE.