Is tranexamic acid (TXA) beneficial in the prehospital environment for traumatic injury with significant bleeding?

From the Guidelines

Tranexamic acid (TXA) is beneficial in the prehospital environment for traumatic injury with significant bleeding and should be administered as early as possible, ideally within 3 hours of injury. The most recent and highest quality study, 1, supports the use of TXA in the prehospital setting, with a strong recommendation for its administration within 3 hours of injury.

Key Points:

• TXA should be administered at a dose of 1 gram infused intravenously over 10 minutes, followed by a second 1 gram dose over 8 hours if ongoing bleeding is present.
• The initial 1-gram bolus is most critical for prehospital use.
• TXA works by inhibiting fibrinolysis, promoting hemostasis, and reducing blood loss in trauma patients.
• The medication is most effective when given early after injury, with diminishing benefits after 3 hours and potential harm if administered beyond that timeframe.
• TXA is particularly beneficial for patients with hypotension, tachycardia, or other signs of shock due to hemorrhage.
• The medication has a good safety profile with minimal side effects when used appropriately, though providers should be aware of contraindications including known hypersensitivity to TXA, active thromboembolic disease, or subarachnoid hemorrhage.
• TXA is cost-effective and stable at room temperature, making it practical for prehospital use in various environments.

Administration Considerations:

• TXA should be administered as soon as possible, if feasible en route to the hospital, and within 3 hours after injury 1.
• The administration of TXA should not await results from a viscoelastic assessment 1.
• Protocols for the management of bleeding patients should consider administration of the first dose of TXA at the site of injury 1.

From the Research

Benefits of TXA in Prehospital Environment

• TXA has been shown to reduce mortality in the treatment of traumatic hemorrhage, with the most profound effect when given early after injury 2, 3, 4
• The use of TXA in the prehospital setting is supported by available data, which suggests that its implementation offers a survival advantage to many patients, particularly when evacuation to surgical care may be delayed 3, 5, 4
• A loading dose of 1 g of TXA, followed by 1 g infusion over 8 hours, given by intravenous administration within a 3-hour window period of traumatic injury, is recommended to achieve the best possible outcomes 5

Safety and Feasibility of TXA in Prehospital Environment

• TXA is very effective and safe to use in the prehospital setting, and its use is clinically and economically feasible 5
• However, treatment with TXA has been associated with increased risk of venous thromboembolic events 2, 6
• The safety profile of TXA in the prehospital setting is similar to that in the emergency department (ED) 2

Timing of TXA Administration

• Early administration of TXA (<45 minutes from injury) may be associated with lower rates of select complications, such as deep venous thrombosis and cerebral vasospasm 6
• However, no mortality benefit was observed in patients who received TXA within 45 minutes of injury, compared to those who received it later 6
• Prehospital administration of TXA within three hours of injury may reduce mortality through improved hemorrhage control 4

Specific Considerations

• In pediatric trauma, preliminary evidence suggests that TXA may lower in-hospital mortality in hemodynamically unstable patients, though higher doses may increase seizure risk 4
• In patients with moderate or severe traumatic brain injury (TBI), TXA administration within 45 minutes of injury may be recommended to reduce select complications 6