January 17, 2025

Welcome to UH EMS-I’s Pharmacy Phriday. As we continue to review recent changes to the UH Prehospital Care Protocol, our focus for this episode will be on the use of tranexamic acid (TXA) in the pediatric patient. 

You may recall a change in the UH protocols last year that allowed the administration of TXA by Advanced EMT providers. The most recent change involving TXA is not an additional use but a change to allow the medication to be used without the need for online medical direction when dealing with a pediatric trauma patient suffering from uncontrollable bleeding and hypovolemia. 

To review, TXA 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, so it does not create or form new blood clots. 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) by stabilizing clots that have formed.  

According to an UpToDate® article, hypovolemia due to blood loss remains the most common cause of shock in the pediatric trauma patient. The article recognized that TXA has been associated with a significant reduction in mortality when given within three hours of blunt or penetrating trauma to the adult patient and highlighted that evidence suggests that TXA may have similar benefits in severely injured children as well.  

Our protocols reflect this approach to trauma care. TXA is considered within the algorithms for: 

• abdominal trauma 

• chest trauma 

• extremity/amputation trauma 

• maxillofacial trauma resulting in nose bleeds or bleeding from a missing tooth 

• multiple trauma 

In the OB emergencies algorithm, TXA can also be considered in post-partum hemorrhage. 

Once again, TXA was referenced in the pediatric algorithms but required online medical direction before it could be administered causing possible harmful delays. With the changes, the pediatric patient who meets the criteria for its use (i.e., uncontrolled hemorrhage, recent trauma <1 hour, age-appropriate vital signs that indicate hypotension, etc.) may receive the medication without delay of contacting online medical direction. 

Remember that IV fluid resuscitation of 20 ml/kg to a systolic pressure of 70 + 2x the patient’s age is still considered the primary management in these cases. TXA would follow once the fluid resuscitation begins. 

TXA is normally supplied as 1 gram in a 10 ml vial. Dosing for the pediatric patient is weight-based at 15 mg/kg mixed in a 100 ml bag of D5W or normal saline and infused over 10 minutes to a max dose of 1 gram. For the adult patient, dosing calls for 2 grams to be mixed in a 100 ml bag and then infused over a 10-minute period. When using a 10 drop set the rate would be approximately 2 gtt/sec. With a 15 drop set the rate would be approximately 3 gtt/sec.  

In cases of epistaxis or a bleeding tooth socket, the medication is mixed as normal and used to soak a gauze product which is then inserted into the nostril or tooth socket to assist with bleeding control. In cases of non-traumatic bleeding and shock, the use of TXA still requires approval from medical direction before administration. 

Contraindications to the use of TXA include hypersensitivity to the medication, or suspected stroke, heart attack, or pulmonary edema. Side effects of TXA can include anaphylaxis, possible thrombosis, nausea, vomiting, diarrhea, and visual disturbances. Hypotension with rapid infusion is often listed as a possible side effect as well, however, there is some thought that it may not be a true side effect. As always, it is important to monitor your patient during and after the administration of a medication. 

Once again, for the most recent UH protocols click here or visit the uhems.org website. 

Till next time, stay safe!  

Sincerely, 

The UH EMS-I Team 

University Hospitals 

August 9, 2014

Welcome to this week’s UH EMS-I’s Pharmacy PHRiday. Recent changes to the State of Ohio EMS Scope of Practice have constituted changes to the UH Prehospital Care Protocol. Over the next few installments of Pharmacy PHRiday, we will focus on those changes as they relate to our drug boxes and medication sections of the protocol. 

One of those recent changes has included tranexamic acid, or TXA, to the list of approved medications that can be administered by the Advanced EMT (please click here for the news release from the Ohio EMS site). Though TXA was the focus of one of our earlier installments this year, this update is well-timed for the Advanced EMT training and is being shared as a refresher for our Paramedic providers. 

TXA 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 with hemophilia. TXA is considered an antifibrinolytic, meaning 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. However, 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) by stabilizing clots that have formed.  

TXA can 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 

• OB emergencies algorithm for post-partum hemorrhage in the adult patient 

TXA Indications and Contraindications

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 10 minutes (approximately 2 gtts/sec if using a 10 drop/ml set, 3 gtts/sec if using a 15 drop/ml set). In cases of epistaxis or a bleeding tooth socket, the medication is mixed as normal and used to soak a gauze product, then inserted into the nostril or tooth socket to assist with bleeding control. In cases of non-traumatic bleeding and shock, the use of TXA currently requires approval from medical direction before administration. 

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 before administration. Dosing is typically weight-based at 15 mg/kg mixed in a 100 ml bag and infused over 10 minutes.  

Side effects of TXA can include: 

• anaphylaxis 

• diarrhea 

• nausea 

• possible thrombosis 

• visual disturbances  

• vomiting  

Hypotension with rapid infusion is often listed as a possible side effect too, but there is some thought that this may not be true. As always, it is important to monitor your patient during and after the administration of a medication.  

For the most recent UH protocols, click here or visit the uhems.org website. 

Till next time, stay safe!

Sincerely,



The UH EMS-I Team

University Hospitals

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

[1] https://www.itrauma.org/wp-content/uploads/2020/01/Current-Thinking-TXA-Resource-Document-Update-FINAL-November-2019.pdf