From the Guidelines
Tranexamic acid (TXA) is beneficial for EMS units when treating patients with significant hemorrhage, and it should be administered as soon as possible, ideally within 3 hours of injury. The recommended dose is 1 gram infused intravenously over 10 minutes, followed by a second 1-gram dose over 8 hours if the patient reaches the hospital 1. For EMS field use, the initial 1-gram bolus is most critical. TXA works by inhibiting fibrinolysis, which helps stabilize blood clots that have formed at injury sites. It is particularly valuable for trauma patients with suspected internal bleeding, patients with significant external hemorrhage, and those with risk factors for coagulopathy. Some key points to consider when administering TXA in the field include:
- Storage at room temperature and protection from light
- Contraindications such as hypersensitivity to TXA, active thromboembolic disease, subarachnoid hemorrhage, and severe renal impairment
- Potential adverse effects such as hypotension if administered too rapidly
- The need for proper training on administration techniques and recognition of appropriate patients When used appropriately, TXA can reduce mortality in bleeding trauma patients without significant increases in thromboembolic complications, as supported by recent guidelines 1. The European guideline on management of major bleeding and coagulopathy following trauma recommends TXA administration as soon as possible, if feasible en route to the hospital, and within 3 hours after injury 1. Additionally, a study published in 2023 found that early treatment with TXA can reduce the risk of death due to bleeding in patients with mild and moderate head injury 1. Overall, the use of TXA in EMS units has the potential to improve outcomes for patients with significant hemorrhage, and its administration should be considered a priority in these situations.
From the Research
Benefits of TXA in EMS Units
- Tranexamic acid (TXA) has been shown to reduce mortality in the treatment of traumatic hemorrhage, with the most profound effects when given early after injury 2, 3.
- Early administration of TXA has been associated with a significant reduction in avoidable trauma mortality, with an estimated 3409 deaths per year potentially averted nationally if TXA is given within one hour of injury 4.
- TXA plays a central role in the development of remote damage-control resuscitation (RDCR) strategies, which aim to improve prehospital hemorrhage control and resuscitation 3.
Safety and Efficacy of TXA in EMS Units
- The safety and efficacy of TXA have been supported by available data, including a large randomized controlled trial (CRASH-2 study) and several cohort studies 3.
- However, there is a significant and paradoxical increased risk of death due to bleeding if TXA is given more than 3 hours after traumatic injury 5.
- The use of TXA has been associated with an increased risk of venous thromboembolic events, highlighting the need for refined protocols to identify patients with severe hemorrhagic shock or traumatic brain injury 2.
Barriers to TXA Use in EMS Units
- Lack of awareness of the clinical data supporting TXA use is a major barrier to its adoption, with only half of responders reporting being aware of TXA as part of their institution's massive transfusion protocol 6.
- Most trauma providers and emergency physicians have a favorable view of TXA and support its incorporation into massive transfusion protocols, but more studies are needed to address the barriers to its use 6.