Tranexamic Acid (TXA)
Tranexamic Acid (TXA)
antifibrinolytics
January 12, 2024
Welcome back to UH EMS-I’s Pharmacy Phriday. In this installment, we continue our focus on some of the protocol changes in 2024, with attention to those involving medications. This week, we will review Tranexamic Acid, or TXA, and the addition of its use in another emergency we may encounter with our patients.
TXA is a medication we continue to become more familiar with. It is a synthetic medication that has been around for many decades, approved by the FDA for use in treating heavy menstrual bleeding and short-term prevention in patients suffering from hemophilia. TXA is considered an antifibrinolytic, which essentially means it prevents or slows the breakdown of fibrin when formed in a blood clot. The medication is not a pro-coagulant, meaning it does not create or form new blood clots. But when used in the trauma patient, it is believed to help reduce the incidence of trauma-induced coagulopathy (think about the trauma triad; we have heard so much about coagulopathy, hypothermia, and acidosis).
Trauma is just one of the “off-label” uses where TXA has been added for our consideration in the prehospital setting in which we operate. Others include severe post-partum bleeding, severe nose bleeds, and other non-traumatic bleeding. It is a well-researched drug and has many uses to help reduce blood loss. It has been demonstrated to have a low side effect profile and is safe to administer in most instances.
Studies continue to look at the use of TXA in trauma and in the prehospital setting. Some question its impact on patients’ survivability and functional outcomes over the long term. However, TXA is still considered beneficial in reducing short-term mortality when administered in a timely manner following an injury. Despite this question of the long-term effect on the trauma patient, the ITLS position on the use of TXA has remained the same since 2019. “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.”[1] Some have investigated methods to provide TXA to more victims in a timely manner in mass casualty settings.
An additional use for TXA within the 2024 UH EMS Protocol is for bleeding from a tooth socket that cannot be controlled using BLS methods. In addition to this use, TXA can also be found as a consideration within the algorithms for abdominal trauma, chest trauma, extremity/amputation trauma, multiple trauma, maxillofacial trauma resulting in nose bleeds or bleeding from a missing tooth, as well as in the OB emergencies algorithms for post-partum hemorrhage in the adult patient.
Criteria for the administration of TXA generally include evidence of current or previous uncontrolled bleeding, with signs of hemorrhagic shock that include sustained tachycardia greater than 120 and/or hypotension with a systolic BP lower than 90 mm/hg in a patient that is greater than 16 years of age. Per protocol, the medication should also be given within the first hour from the time of injury. TXA can also be considered for use in cases of non-traumatic bleeding (such as vaginal bleeding) within the same parameters as mentioned above, but only after consultation with medical direction. Contraindications to its use include known allergies and cases involving clotting such as CVA, MI, PE, etc.
TXA is normally supplied as 1 Gram in a 10 ml vial. Dosing calls for 2 grams to be mixed in a 100 ml bag of D5W or Normal Saline to be infused over a 10-minute period (approximately 2 gtts/sec if using a 10 drop/ml set, 3 gtts/sec if using a 15 drop/ml set). Infusing the medication too quickly can cause additional hypotension. In cases of epistaxis or a bleeding tooth socket, the medication is mixed as normal and used to soak a gauze product that is then inserted into the nostril or tooth socket to assist with bleeding control.
UH protocol does permit the use of TXA in pediatric patients with epistaxis or a bleeding tooth socket, as noted above. Any other use in the pediatric patient must be approved by medical direction prior to administration. Dosing is typically weight-based at 15 mg/kg mixed in a 100 ml bag and infused over 10 minutes.
Till our next Pharmacy Phriday, stay safe!
Sincerely,
The UH EMS-I Team
University Hospitals