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.
Death due to bleeding was significantly reduced in women given tranexamic acid (155 [1·5%] of 10 036 patients vs 191 [1·9%] of 9985 in the placebo group, risk ratio [RR] 0·81, 95% CI 0·65–1·00; p=0·045), especially in women given treatment within 3 h of giving birth (89 [1·2%] in the tranexamic acid group vs 127 [1·7%] in the placebo group, RR 0·69, 95% CI 0·52–0·91; p=0·008).
- 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.
- The headline here is that those with an extradural and fixed dilated pupils have a >50% chance of a good neurological recovery. Please, please, please aggressively manage these patients and avoid any nihilism as a result of this pupilary sign.
- Give Tranexamic acid to all patients with massive bleeding within 3 hours of trauma
- Use Ketamine for all trauma intubation so
Tranexamic acid (1g given over 10 min (IVI) followed by 1g given over 8h (IVI)) can save 1 in 67 patients with severe trauma
CRASH-2: A large multicenter randomised control trial of 20,211 patients (CRASH2) found:
The most severely injured patients who received TXA had the highest reduction in mortality. Benefits were greatest for those treated within 3 hours of injury and subgroup analysis demonstrated that TXA was most effective in patients with shock (systolic blood pressure < 75 mmHg).
Recently, there has been a lot of buzz about the use of topical tranexamic acid for epistaxis or oral bleeds on multiple social media platforms. Everyone seems so happy that it works so well, but we thought we would look through the literature and see what the evidence for use of topical tranexamic acid (TXA) is and how best to compound it for these clinical dilemmas. We performed a PubMed, and Ovid search using the terms “topical” AND/OR “oral solution” AND/OR “intranasal” PLUS “tranexamic acid” to answer our questions at hand.