TXA is a safe, inexpensive medication that prevents fibrin breakdown. In traumatic bleeding, it conveys a significant mortality benefit with an impressive NNT for mortality between 7 and 67, depending on injury severity, without apparent serious safety issues. This benefit is associated with early administration. TXA should not be given more than three hours after injury as it may increase mortality after this timeframe. It appears to have equal benefit in a variety of trauma practice environments.
- The most important step in managing a bleeding trauma patient is surgical source control – most patients with massive hemorrhage need an operation to stay the hemorrhage. The state in which a patient arrives to the operating room or the intensive care unit – alive or near death, cold and coagulopathic or warm and well perfused – is up to you.
Excessive crystalloid administration is associated with hypothermia, coagulopathy and death in bleeding patients. If you think your patient is bleeding and you have ready access to blood products, you can skip crystalloid all together and go straight for the good stuff.
Trauma patients don’t just bleed red blood cells. They lose plasma, platelets and clotting factors, too. Give blood products (red cells, plasma, platelets) in a balanced 1:1:1 ratio (to mimic whole blood) or give whole blood.
Tranexamic acid (TXA) is an anti-fibrinolytic agent that can/should be used early in the resuscitation of bleeding trauma patients. 1gm of TXA given as an early bolus followed by an infusion of 1gm over the ensuing 8 hours has been associated with an absolute risk reduction of 1.5%.
If you resuscitate based a trauma patient based on vital signs alone, you will under-resuscitate about 50% of trauma patients. The foley catheter is an essential adjunct during massive resuscitation. If your patient is making urine at a rate of > 50ml/h, your resuscitative efforts are probably adequate.