At least in the United States, the GOLD standard of prehospital trauma care has been appreciating the importance of the “GOLDen hour.” This concept of getting the patient to the closest appropriate trauma center quickly has time and time-again, proven to save lives. The idea is that prehospital crews have very few treatment options when it comes to advanced trauma care. While rapid transport to a trauma center is still the goal of prehospital trauma care, we are slowly obtaining treatment options that help bridge the gap between the time the injury occurs, to when the patient is on the operating table. While most of us are currently using things like pelvic binders, tourniquets and hemostatic dressing, something that you may not be familiar with is a drug known as Tranexamic Acid (or TXA).
TXA is classed as an antifibrinolytic. It basically works by preventing plasminogen from being converted into plasmin (the key component in clot breakdown). This helps preserve already formed clots, and reduces the incidence of bleeding. TXA was originally developed and administered as a perioperative measure to reduce bleeding in patients with hemophilia during tooth extraction. It was eventually being used in the surgical setting to reduce the need for blood transfusions during major orthopedic and general surgery. Eventually TXA was used to treat patients with uterine bleeding associated with fibroids. After looking at how TXA works and the success it was having in these areas of medicine, it was theorized that it could be used in the trauma patient with suspected uncontrolled hemorrhage (internal and external).
This prompted a series of clinical trials to test the efficacy of TXA administration in the trauma patient. Both the CRASH-2 and MATTERS trials demonstrated a significant reduction in morbidity in the trauma patient if TXA was given early. The MATTERS trial (a military trial that tested early use of the TXA) showed that if TXA was given within 3 hours of the injury, the patient had a higher likelihood of survival. Inversely, if TXA was given greater than 3 hours of the injury, the patients had worse outcomes than if TXA was withheld. This data begged the question, “does TXA have a place in the prehospital setting?” The answer appears to be “YES!” with one caveat.
TXA given in the prehospital setting does establish mortality benefit as long as the drug is given within 3 hours of injury. The only exception to this is that the administration of TXA should not delay the patient’s transport to a trauma facility. The important thing to remember about TXA is that it does not fix the issue of having a life-threatening injury. Rather, it helps the patient survive transport to the hospital. Several agencies (both ground and flight) around the world have adopted TXA. Time will be the real test to see if TXA is effective enough to hold a place in our respective drug-boxes.
QUICK NOTES ON TXA
- Treatment needs to be initiated within 3 hours after injury.
- Given to patients with suspected uncontrolled blood loss.
- Patient has signs of hypovolemic shock secondary to trauma.
- Treat all life threatening injuries prior to administration of TXA (tourniquets, hemp static agents, gauze and compression bandages)
- 1 gm in a 100 ml bag of normal saline over 10 minutes IV
- Initiate maintanence dose of 1 gm in 1000 ml NS give at a rate of 60 ml/hr for a total of 6 hours.
CLINICAL TRIALS ON TXA