Tranexamic Acid (TXA) in Trauma Patients

Tranexamic Acid (TXA) is a synthetic reversible competitive inhibitor to the lysine receptor found on plasminogen and the activated form of plasminogen, plasmin. This binding inhibits fibrinolysis, the breakdown fibrin matrix, thereby stabilizing blood clots. Simply put, TXA stabilizes blood clots that have formed and help prevent them from getting broken down.

Intravenous TXA is used in EMS for hemodynamically unstable patients from trauma, post-partum hemorrhage, heavy vaginal bleeding, and epistaxis. There are 2 important studies about the use of TXA.

The 2010 CRASH-2 trial was a multi-center randomized, double-blind, controlled trial comparing TXA to a placebo in adult trauma patients. The patients included in the study had significant hemorrhage with a heart rate greater than 110 bpm and systolic blood pressure less than 90 mmHg. The study found that TXA improved survival when administered within three hours of the injury in a patient population with substantial hemorrhage. The 2011 MATTERs trial was a retrospective observational study attempting to validate CRASH-2 by studying patients with traumatic injuries in combat who received at least one unit of blood within 24 hours of presentation. The MATTERs trial demonstrated that TXA decreased overall mortality.

The indication and dosing for TXA has changed over the last few months. Remember that any trauma patient who appears 16 years or older is treated as an adult. TXA is indicated in ADULT trauma patients with sustained heart rate >120 bpm or systolic blood pressure < 90 mmHg. The new ADULT dosing is to mix 2 grams (2000 mg) in 100 ml of D5 and administer that dose over 10 minutes. There are now 2 vials or ampules in the drug box, each containing 1 gram (1000 mg) of medication. You will add vials or ampules to the 100 ml D5 bag to prepare the medication for infusion. TXA has also recently been added to the PEDIATRIC protocol. TXA is indicated in PEDIATRIC trauma patients under the age of 16 with uncontrolled bleeding and hemodynamically unstable. Also, remember that vital signs are different for children than adults. Normal ranges for heart rate and blood pressure vary by the patient’s age, so always refer to a pediatric vital sign chart. The PEDIATRIC dose is to mix 15 mg/kg, max of 1000 mg, of TXA in 100 ml of D5 and administer that dose over 10 minutes. TXA is contraindicated in patients who are hypersensitive, have a suspected cerebral vascular accident, myocardial infarction, or pulmonary embolism.

John B. Hill, MD

Emergency Medicine Physician

UH Portage EMS Medical Director

UH Portage ED Trauma Liaison

The Triad of Death - February 13, 2023

The Trauma Triad of Death

The triad consists of three interrelated conditions that can lead to death if not managed promptly: ACIDOSIS, COAGULOPATHY, and HYPOTHERMIA, which are centered around HEMORRHAGE.

When trauma occurs, tissue is damaged, and blood is lost. The HEMORRHAGE can be obvious, on the ground, or devious, and blood can hide in body compartments such as the chest, abdomen, pelvis, or thigh. As the body loses blood, more tissue damage occurs as cells are starved of the oxygen carried in the blood. Without oxygen, the deprived cells switch to anaerobic metabolism creating lactic acid. As lactic acid builds up in tissues and enters the bloodstream, it lowers the pH in the body, called ACIDOSIS. 

ACIDOSIS has several negative effects, including decreased cardiac output, arterial dilatation with hypotension, arrhythmias, impaired immune system, and decreased function of the clotting cascade, with adverse effects on bleeding control. When blood is unable to clot on its own, this is known as COAGULOPATHY, and is made worse by the loss of clotting factors from HEMORRHAGE and the depletion of the remaining clotting factors used to stop the bleeding. As COAGULOPATHY worsens, the HEMORRHAGE continues, and ACIDOSIS exacerbates, leading to HYPOTHERMIA.

HYPOTHERMIA happens because of severe blood loss or exposure to cold. When a patient becomes hypothermic, their body begins to conserve heat by reducing blood flow to the skin and extremities. It causes a decrease in oxygen and nutrient delivery to these areas, which can lead to tissue damage and organ failure, which worsens ACIDOSIS. The body attempts to compensate by increasing heart and respiratory rate, accelerating HYPOTHERMIA.

All these conditions are interconnected and can contribute to a vicious cycle that can quickly lead to DEATH. EMS can manage the trauma triad of death by taking a systematic approach to patient care which includes:

• rapidly identifying and treating HEMORRHAGE, HYPOTHERMIA, ACIDOSIS, and COAGULOPATHY. 

• EMS can place tourniquets

• position a pelvic binder

• pack a wound

• move patients from cold environments

• remove wet clothes

• prevent hypercapnia

• treat with diesel at the nearest trauma center

John B. Hill, MD

Emergency Medicine Physician

UH Portage EMS Medical Director

UH Portage ED Trauma Liaison

Shock in Trauma - February 20, 2023

Shock in Trauma

Shock is a state of cardiovascular insufficiency that creates an imbalance between tissue oxygen supply and demand, resulting in end-organ dysfunction. Shock is typically divided into four categories: 

• Hypovolemic

• Distributive

• Cardiogenic

• Obstructive

The four categories of shock can be described in terms of their respective physiologic changes and common causes; however, overlap is common. This table from Tintinalli’s Emergency Medicine is a quick review of the categories.

We focus on hypovolemic shock typically seen in trauma, but remember, trauma patients could present with any type of shock based on the injury sustained. Hypovolemic shock occurs when decreased blood volume from hemorrhage causes decreased preload, stroke volume, and cardiac output. This leads to decreased myocardial oxygenation, decreasing contractility, and cardiac output leading to a hemodynamic downward death spiral. The clinical presentation of acute hypovolemic shock depends on the rate, total volume, and duration of bleeding; medication affects age and the patient’s baseline status.

The body’s response to acute hemorrhage is to shunt blood to vital organs and away from the periphery. This results in cool, pale, and clammy extremities. Patients can develop tachycardia, hypotension, prolonged capillary refill, narrowing of the pulse pressure, anxiety, confusion, or lethargy. With increasing blood loss, the signs and symptoms become more pronounced and occur in a predictable manner that is broken into four main classes:

• Class 1 hemorrhage: a minimal amount of bleeding and involves the loss of up to 15% of the body's blood volume. It typically does not cause significant symptoms, and the body can compensate for the blood loss without intervention.

• Class 2 hemorrhage: a mild form of blood loss and includes the loss of 15% to 30% of the body's blood volume. It can cause tachycardia (100-120 bpm), narrowed pulse pressure (<30), tachypnea (30-40rr), anxiety, and confusion.

• Class 3 hemorrhage: a moderate form of blood loss and entails the loss of 30% to 40% of the body's blood volume. It can cause tachycardia (120-140 bmp), narrowed pulse pressure (<30), tachypnea (30-40 rr), anxiety, and confusion. 

• Class 4 hemorrhage: a severe form of hemorrhage involving the loss of more than 40% of the body's blood volume. It can cause tachycardia (>140 bmp), narrowed pulse pressure (<30), tachypnea (>35 rr), confusion, and lethargy.

Severe hemorrhage after injury carries a mortality rate of 30% to 40% and is responsible for almost 50% of deaths occurring within 24 hours of injury. Resuscitation of hypovolemic shock starts in the prehospital setting by stopping blood loss and maintaining adequate tissue perfusion. EMS does this by applying tourniquets and pelvic binders, obtaining intravenous or intraosseous access, administering TXA, resuscitating with fluid, and transporting to a trauma center. Remember, the goal is to maintain a mean arterial pressure of 65 in these patients. 

John B. Hill, MD

Emergency Medicine Physician

UH Portage EMS Medical Director

UH Portage ED Trauma Liaison

Adult Abuse - February 27, 2023

Adult Abuse

Adult abuse is a serious problem that affects many vulnerable people in our society. Adult abuse can be physical, emotional, sexual, exploitation, or neglect. It can happen to anyone 60 years or older or with a disability that makes them dependent on others for care. Adult abuse can cause physical injuries, mental distress, financial losses, and even death. The Ohio Department of Job and Family Services (ODJFS) supervises the Ohio Adult Protective Services program. For Ohio state fiscal year 2020, a total of 33,783 reports were received, resulting in 17,022 individuals needing protective services, two-thirds of which agreed to receive services.

It is important to know that you do not need proof of abuse to make a report. Job and Family Services will investigate to determine if abuse has occurred and what actions are necessary. Individuals are protected from retaliation by law when they report adult abuse in good faith. Reporting adult abuse is important because it can help stop the abuse, protect the victim from further harm, and help the abuser get treatment or counseling if needed. Reporting adult abuse is not only a moral duty but also a legal obligation for EMS, social, medical, and mental health care professionals, as well as attorneys, peace officers, senior service providers, coroners, clergymen, and professional counselors.

The most common types of elder abuse reported in Ohio are neglect, self-neglect, exploitation, and emotional, physical, and sexual abuse.

• Neglect is the failure of an adult to provide the goods or services necessary for his or her own safety and/or well-being − such as avoiding physical harm, mental anguish, or mental illness − or the failure of a caretaker to provide such goods or services.

• Exploitation is the unlawful or improper act of a caretaker using an adult or his/her resources for monetary or personal benefit, profit, or gain.

• Physical abuse is the intentional use of physical force that results in injury, pain, or impairment. It includes pushing, hitting, slapping, pinching, and other ways of physically harming a person. It can also mean placing an individual in incorrect positions, force feeding, restraining, or giving medication without the person’s knowledge.

• Emotional abuse occurs when a person is threatened, humiliated, intimidated, or otherwise psychologically hurt. It includes violating an adult’s right to make decisions and the loss of his or her privacy.

• Sexual abuse includes rape or other unwanted, nonconsensual sexual contact. It also can mean forced or coerced nudity, exhibitionism, and other non-touching sexual situations, regardless of the age of the perpetrator.

ODJFS prefers mandated reports. Visit their website to report non-emergent situations to keep the phone number less busy. Anyone who suspects that adult abuse may be occurring can call one statewide toll-free number 24 hours a day, 365 days a year: 1-855-OHIO-APS (1-855-644-6277). Adult abuse also can be reported HERE or to a county JFS agency. To find your nearest JFS agency, visit HERE. If you need to make a report, provide as much of the following information as possible:

• Name, address, and approximate age of the person

• Name and address of the person responsible for the victim’s care

• The name and address of the alleged perpetrator, if different from the caretaker

• The reason you suspect abuse, neglect, or exploitation

• The nature and extent of the suspected abuse, neglect, or exploitation

• Any other known information

Reporting adult abuse can save lives and improve outcomes for victims. Do not hesitate to speak up if you see something wrong. You may be their only hope.

Resources

Ohio Department of Job and Family Services Directory https://jfs.ohio.gov/County/County_Directory.pdf

National Center on Elder Abuse https://ncea.acl.gov/Resources/State.aspx

National Adult Protective Services Association https://www.napsa-now.org/help-in-your-area/

John B. Hill, MD

Emergency Medicine Physician

UH Portage EMS Medical Director

UH Portage ED Trauma Liaison