What is the first line treatment for a patient with a brain bleed or traumatic injury, specifically in terms of medication like Tranexamic Acid (TXA)?

From the Guidelines

Tranexamic Acid (TXA) is the first-line medication for patients with a brain bleed or traumatic injury, and it should be administered as soon as possible, ideally within 3 hours of injury, at a loading dose of 1 g infused over 10 minutes, followed by an intravenous infusion of 1 g over 8 hours 1. The standard dosing regimen of TXA is based on the European guideline on management of major bleeding and coagulopathy following trauma, which recommends administering TXA to the trauma patient who is bleeding or at risk of significant bleeding as soon as possible, if feasible en route to the hospital, and within 3 hours after injury 1. The effectiveness of TXA in reducing mortality and morbidity in trauma patients has been demonstrated in several studies, including the CRASH-2 trial, which showed that early administration of TXA significantly reduced the risk of death due to bleeding 1. In addition to TXA, blood pressure management is crucial in patients with traumatic brain injury, and the goal is to maintain a systolic blood pressure below 140-160 mmHg to prevent hematoma expansion 1. TXA works by inhibiting plasminogen activation, which prevents the breakdown of blood clots and helps maintain clot stability, thereby reducing ongoing bleeding and potentially limiting the size of the hemorrhage 1. Potential side effects of TXA include thrombotic events, so caution is advised in patients with a history of thromboembolism, though the risk appears relatively low in the acute setting 1. Some key points to consider when administering TXA include:

• Administering TXA as soon as possible, ideally within 3 hours of injury
• Using a loading dose of 1 g infused over 10 minutes, followed by an intravenous infusion of 1 g over 8 hours
• Maintaining a systolic blood pressure below 140-160 mmHg to prevent hematoma expansion
• Monitoring for potential side effects, such as thrombotic events
• Considering the use of other medications, such as erythrocytes, cell salvage, and topical haemostatic agents, as needed 1.

From the FDA Drug Label

4 CONTRAINDICATIONS Tranexamic acid is contraindicated: In patients with subarachnoid hemorrhage.

The FDA drug label does not answer the question.

From the Research

First Line Treatment for Brain Bleed or Traumatic Injury

The first line treatment for a patient with a brain bleed or traumatic injury, specifically in terms of medication like Tranexamic Acid (TXA), is as follows:

• TXA has been shown to reduce blood loss in surgical patients and the risk of death in patients with traumatic bleeding, with no apparent increase in vascular occlusive events 2.
• The CRASH-2 trial found that TXA was likely to be associated with a reduction in haemorrhage growth, fewer focal ischaemic lesions, and fewer deaths in patients with traumatic brain injury (TBI) 2.
• The CRASH-3 trial found that early TXA treatment reduces head injury deaths, and is cost-effective for patients with mild or moderate traumatic brain injury, or those with both pupils reactive 3.
• A therapeutic review of TXA in the management of traumatic brain injury, nontraumatic intracranial hemorrhage, and aneurysmal subarachnoid hemorrhage found that TXA may reduce head injury-related mortality in mild-to-moderate injury if treatment occurs within 1 hour of symptom onset, but more data are needed to determine which head injury subpopulations are most likely to benefit from TXA 4.
• A literature review and descriptive analysis of principal themes on the use of TXA for the management of hemorrhage in trauma patients in the prehospital environment found that TXA is very effective and safe to use in the prehospital setting, and its use is clinically and economically feasible 5.
• A study published in Lakartidningen argued that TXA should be administered within 3h post-injury to moderate-severe TBI patients, and in mild TBI to those with intracranial haemorrhage on acute CT, due to its favourable safety profile and the devastating effects from intracranial bleeds 6.

Key Findings

• TXA reduces blood loss and risk of death in patients with traumatic bleeding 2, 3.
• Early TXA treatment is effective in reducing head injury deaths in mild-to-moderate TBI 3, 4.
• TXA is safe and effective in the prehospital setting 5.
• TXA should be considered for administration within 3h post-injury to moderate-severe TBI patients, and in mild TBI to those with intracranial haemorrhage on acute CT 6.

Medication Administration

• The recommended dose of TXA is a loading dose of 1 g, followed by 1 g infusion over 8 hours, given by intravenous administration within a 3-h window period of traumatic injury 5.