The Use of Tranexamic Acid in Traumatic Bleeding Background

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In spite of major improvements in trauma care, traumatic hemorrhage continues to lead as the main cause of preventable death after injury. For this reason there has been a surge of research in blood component therapy and trauma resuscitation. We are left to question our use of crystalloid resuscitation and blood product ratios. In a continued quest to improve outcome tranexamic acid is now under investigation as a cheap and safe means of decreasing hemorrhage in early injury.

Tranexamic acid is an anti-fibrinolytic that blocks the action of plasminogen, an enzyme that dissolves clots. Tranexamic acid has been used for decades to minimize blood loss in surgery, especially cardiac and orthopedic surgery.

Tranexamic Acid will be referred to as TXA at times in this poster.

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Methods

This poster is informational and is meant to educate trauma care providers on tranexamic acid. The method used was literature search only. A recent discussion of tranexamic acid in our institution has lead to some interesting debates on its use in a prehospital setting.

• l One: Review of CRASH-2 trial • Two: Review of MATTERs study • Three: Review of the literature reaction to these studies • l • .

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Holly Hollenbaugh-Fogle RN, BSN, CCRN Children’s Hospital of Pittsburgh of UPMC

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Results

The CRASH-2 randomized controlled trial sought to assess the effect that early administration of tranexamic acid had on death, vascular occlusive events and blood transfusion on patients with traumatic hemorrhage. It involved 274 hospitals, 40 countries and 20,211 patients. 10,096 patients were allocated to tranexamic acid and 10,115 were to placebo. The CRASH-2 study showed that administration of tranexamic acid to adult trauma patients with, or at risk of , significant hemorrhage, within eight hours of injury, significantly reduces all-cause mortality with no apparent increase in vascular occlusive events.(1) Early treatment defined as within 1 hour of injury demonstrated a 5.3% risk of death in the TXA group vs. 7.7% in the placebo group. When treatment was given within 1-3 hours of injury the risk of death for the TXA group was 4.8% vs. 6.1% for the placebo group.

The MATTERs retrospective study of 900 NATO casualties showed there was no difference in mortality between the tranexamic acid group and the placebo group at 24 hours, even though the tranexamic acid group was more severely injured. At 28 days the mortality for the tranexamic acid group was substantially lower and at the 28-day mark, mortality for the TXA group was half of that of the placebo group.(2)

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Conclusion

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Because of the CRASH-2 trial the World Health Organization has added TXA to their list of essential drugs.

Both the British and American military have added TXA to their transfusion protocols.

In the United States, the University of Texas Health Science Center in Houston and the Mayo Clinic in Rochester, Minn. Have added TXA to the drugs to be administered on the medical helicopters and the ED departments.

TXA is best administered within three hours of injury, so in developed countries the best role for TXA may be in a prehospital setting.

Tranexamic acid is safe, effective and cheap with few contraindications or adverse reactions.

Tranexamic acid has the potential to be an exciting new “tool” in our kit to treat traumatic bleeding and warrants our serious attention as we try to find answers to the best way to volume resuscitate our trauma patients.

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References

Insert your references here 1.The CRASH-2 Collaborators. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant hemorrhage(CRASH-2): a randomised, placebo-controlled trial. Lancet 2010; 376:23-32..

2.Morrison JJ, Dubose JJ,Rasmussen TE,Midwinter, MJ. Military Application of Tranexamic Acid in Trauma Emergency Resuscitation(MATTERs) Study. Arch Surg 2012; 147:113-9..