Role of TXA in Management of Traumatic Hemorrhage in the Field

INTERNATIONAL TRAUMA LIFE SUPPORT

ROLE OF TXA IN MANAGEMENT OF TRAUMATIC HEMORRHAGE IN THE
FIELD

Roy Alson, MD, PhD, FACEP, FAAEM and Sabina Braithwaite, MD, MPH, FACEP

The guidelines and references contained in this document are current as of the date of
publication and in no way replace physician medical oversight.
Original Publication Date: July 2014.
Updated October 2016.

INTRODUCTION

Hemorrhagic shock remains a serious problem for the multiple trauma patient. It is the leading
cause of preventable trauma deaths after loss of airway. Rapid and effective control of
exsanguinating hemorrhage has been demonstrated to markedly improve survival and
outcome, especially in the combat environment. Increased use of tourniquets has reduced
death from hemorrhagic shock in the most recent wars fought by U.S. and NATO forces.
The tactical and military environment is associated with a higher percentage of penetrating
trauma and external hemorrhage than is seen with the civilian sector, in which blunt trauma
predominates. This leads to the situation of ongoing hemorrhage that is difficult to control.
Prompt recognition of this with transport to the appropriate facility (Trauma Center) and
limiting fluid resuscitation to the level of restoring perfusion (hypotensive resuscitation) have
been shown to result in improved survival for the trauma patient.

BACKGROUND

Tranexamic acid (TXA) is an antifibrinolytic that has been used for many years to assist with the
management of spontaneous hemorrhaging in the hemophilia patient. The use of this agent for
management of hemorrhage in combat wounds has been reported in several papers. One of
the most significant findings in the CRASH-2 study is that the use of TXA is associated with a 1.5
absolute risk reduction for death from hemorrhage. Other studies show that TXA is most
effective if given within 3 hours of the injury and may be detrimental if given after that time.
TXA Resource Document © International Trauma Life Support – 2014, 2016

CONSIDERATIONS

The side effects of the agent are minimal and the contraindications are few. It is administered
as a simple IV infusion, does not require refrigeration or extensive laboratory studies to allow
administration (as is seen with blood products) and is inexpensive. (NOTE: Use for traumatic
hemorrhage is an off label use per FDA in the United States.)

PROCEDURE

Based on local protocols and clearance, TXA should be considered in those patients who show
signs of hemorrhagic shock, including tachycardia (>110 BPM) and hypotension (SBP<100) and
are less than three hours from injury. Do not give TXA through the same line as blood products.

MEDICAL OVERSIGHT

Medical oversight should review current literature and develop pre-hospital EMS protocols in
regard to appropriate use of TXA. Implementation of this protocol should be monitored and
supervised through a quality assurance program.

CONCLUSION

ITLS believes that there is sufficient evidence to support the use of TXA in the management of
traumatic hemorrhage in the adult patient, pursuant to system medical control approval.
Following initial resuscitation including control of external bleeding and stabilization of airway,
consideration should be given to administration of TXA during early stages of transport.

UPDATES – OCTOBER 2016

While there is no current dispute on the merits of TXA in patients with severe extracranial
hemorrhage as stated above, a 2015 systematic review was undertaken of two relevant
completed randomized trials looking at the effectiveness and safety of TXA in polytrauma with
traumatic brain injury. In a meta-analysis there is a statistically significant reduction in
intracranial hemorrhage. However because the confidence intervals are wide, the quality of this
evidence is low. Therefore, the effectiveness and safety of TXA in traumatic brain injury are
uncertain although randomized trials are underway to investigate the problem. The authors
recommend that patients with isolated traumatic brain injury should not receive TXA outside
the context of a randomized trial.
TXA Resource Document © International Trauma Life Support – 2014, 2016

REFERENCES

1. Morrison JJ, et al. Military application of tranexamic acid in trauma emergency
resuscitation (MATTERs) study. Arch Surg, 2012 Feb; 147(2): 113—9.
2. Shakur H et al, Effects of tranexamic acid on death, vascular occlusive events, and blood
transfusion in trauma patients with significant hemorrhage (CRASH-2): a randomized,
placebo-controlled trial. Lancet, 2010 Jul 3; 376(9734): 23–32.
3. Kobayashi L, Costantini TW, Coimbra R. Hypovolemic shock resuscitation. The Surgical
clinics of North America. 2012;92(6):1403-23.
4. Rappold JF, Pusateri AE. Tranexamic acid in remote damage control resuscitation.
Transfusion. 2013;53 Suppl 1:96S-9S.
5. Collaborators C-. Effect of tranexamic acid in traumatic brain injury: a nested
randomised, placebo controlled trial (CRASH-2 Intracranial Bleeding Study). British Med
Journal. 2011;343:d3795.
6. Ker K, Edwards P, Perel P, Shakur H, Roberts I. Effect of tranexamic acid on surgical
bleeding: systematic review and cumulative meta-analysis. British Med Journal.
2012;344:e3054.
7. Lockey DJ, Weaver AE, Davies GE. Practical translation of hemorrhage control
techniques to the civilian trauma scene. Transfusion. 2013;53 Suppl 1:17S-22S.
8. Cap AP, Baer DG, Orman JA, Aden J, Ryan K, Blackbourne LH. Tranexamic Acid for
Trauma Patients: A Critical Review of the Literature. Journal of Trauma-Injury Infection
& Critical Care. 2011;71(1 Supplemental):S9-S14.
9. Mahmood A, Roberts I, Shakur H, Harris T, Belli A. Does tranexamic acid improve
outcomes in traumatic brain injury? British Med Journal. 2016:354:i4814.
TXA Resource Document © International Trauma Life Support – 2014, 2016

Current Thinking
Role of TXA In Management of Traumatic
Hemorrhage In The Field

International Trauma Life Support
The guidelines and references contained in this document are current as of the date of
publication and in no way replace physician medical oversight.
Original Publication Date: July 2014.
Updated October 2016.

Abstract

This is the official current thinking of International Trauma Life Support (ITLS) with regard to the
role of TXA in management of traumatic hemorrhage in the pre-hospital setting.

Current Thinking

It is the position of International Trauma Life Support that:
1. There is sufficient evidence to support the use of TXA in the management of traumatic
hemorrhage in adult trauma patients.
2. ITLS supports the use of TXA in the acute management of traumatic hemorrhagic shock
within the framework of established system medical oversight and protocols.
3. Use of TXA is recommended in conjunction with initial resuscitation and control of
external bleeding. Early TXA administration should be considered following airway
stabilization, control of external bleeding, and initial volume resuscitation.
4. The use of TXA should be considered during the early stages of resuscitation and
transport. Current research demonstrates TXA is most effective if given within 3 hours
of the injury and may be detrimental if given after that time.
5. With reference to Updates-October 2016, ITLS recommends that patients with isolated
traumatic brain injury should not receive TXA outside the context of a randomized trial.

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