Tranexamic acid (TXA) for Trauma

From Guide to YKHC Medical Practices



CONVENTIONAL DOSING

One gram in 100mL saline infused over 10 minutes (initiated within 3 hours of injury), followed by one gram over 8 hours.

ALTERNATE DOSING

The U.S. Military is now recommending a SINGLE DOSE of 2 grams slow IV/IO push (over 1 minute) within 3 hours of injury.[1]

DISCUSSION

In the fall of 2020 the United States Department of Defense (DOD) Committee on Tactical Combat Casualty Care (CoTCCC)[2] updated the Tactical Combat Casualty Care (TCCC) guidelines to specify that TXA should be administered as a single dose of 2 grams slow IV/IO push (over 1 minute). This adoption of 2 gram bolus dosing was mainly driven by the outcomes a recent civilian, multi-center RCT which compared the 2 gram bolus dosing (n=345) to either conventional dosing (n=312) or placebo (n=309) in the prehospital phase of care of patients with a head injury and GCS of 12 or less; though the primary outcome showed no difference, among the subset of patients with intracranial hemorrhage on initial head CT, the 2g bolus group had a 35 percent decrease in 28-day mortality (18% versus 28% and 28%, respectively). Additionally, the only adverse effect was increased "seizure like activity" in the 2g bolus dose group (5% versus 2% and 2%, respectively), but this was not associated with any long term effects.[3][4]

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

  1. Limited (or nonexistent) 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[3]) 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.



REFERENCES

  1. TCCC Guidelines. Deployed Medicine. Published November 5, 2020. Accessed November 23, 2021. eBook PDF
  2. Committee on Tactical Combat Casualty Care (CoTCCC) - Joint Trauma System. Accessed November 23, 2021. https://jts.amedd.army.mil/index.cfm/committees/cotccc
  3. 3.0 3.1 Drew B, Auten JD, Cap AP, et al. The Use of Tranexamic Acid in Tactical Combat Casualty Care: TCCC Proposed Change 20-02. J Spec Oper Med. 2020;20(3):36-43. PMID:32969002. https://www.jsomonline.org/AllArticles.php#Article1037
  4. Rowell SE, Meier EN, McKnight B, et al. Effect of Out-of-Hospital Tranexamic Acid vs Placebo on 6-Month Functional Neurologic Outcomes in Patients With Moderate or Severe Traumatic Brain Injury. JAMA. 2020;324(10):961-974. doi:10.1001/jama.2020.8958



Author[s]:
Andrew W. Swartz, MD