# Tranexamic Acid



## goon175 (Jan 19, 2013)

Just wondering what it is and what it does, and why it was a big deal that SSG Hutchinson used it? USASOC Medic of the Year is a big deal, so I'm guessing it must be a difficult thing to administer?

http://www.wtoc.com/story/20626072/...ard?utm_source=twitterfeed&utm_medium=twitter


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## TLDR20 (Jan 20, 2013)

Fucking hutch. I went through SOCM with him. Good on him, he was always a stellar guy.


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## bublik (Jan 20, 2013)

TXA is an antifibrinolytic (inhibits action of plasminogen), in plain language --> stops the breakdown of clots that that body builds in response to bleeding.

Natural progression in bleeding/hemorrhage is that circulating platelets and go through a conformational (shape) change when exposed to tissue factors that are released in damaged vessel lining. The clotting cascade follows and platelets, clotting factors, fibrin, all work together to form a clot.

Final step in coagulation is fibrinolysis (clot breakdown and resorption) --> which is where TXA comes in to play. It stops plasminogen from breaking down the clot.

*TXA key points:*

-Beneficial in casualties anticipated in needing massive transfusion
-Most effective when given early post-injury (within 3hrs, ideally less than 1hr)
-Increased morbidity/mortality when given >3hrs post-injury (not clear on why the 3hr cutoff but if anyone has access to specifics on that I'd be interested)


Lots of words past this line  but evidence supports early TXA use in trauma, the research (CRASH-2, MATTERs, and others) is interesting and it's now incorporated in TCCC.  
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*** The guidelines in bold are from the TCCC reference document "SUBJECT: Recommendations Regarding the Addition of Tranexamic Acid to the Tactical Combat Casualty Care Guidelines 2011-06" I have the PDF saved if anyone wants it or you can access it here http://www.health.mil/Education_And_Training/TCCC.aspx



*Guidelines for Administration in the Deployed Setting *

*The early use of TXA should be strongly considered for any patient requiring blood products in the treatment of combat-related hemorrhage and is most strongly advocated in patients judged likely to require massive transfusion (e.g., significant injury and 3 or 4 risk factors/indicators of massive transfusion).*

*Use of TXA within 3 hours of injury is associated with the greatest likelihood of clinical benefit. The greatest benefit was seen when TXA was administered within 1 hour of wounding.*

*Due to this time constraint, the uncertainty of battlefield evacuation, and a good safety profile in the doses previously administered to trauma patients, use in the prehospital setting is recommended if patient monitoring and storage requirements can be met.*








*Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study.*
Morrison JJ, Dubose JJ, Rasmussen TE, Midwinter MJ.
*Source*
US Army Institute of Surgical Research, Fort Sam Houston, TX 78234-6315, USA.
*Abstract*

*OBJECTIVES:*

To characterize contemporary use of tranexamic acid (TXA) in combat injury and to assess the effect of its administration on total blood product use, thromboembolic complications, and mortality.

*DESIGN:*

Retrospective observational study comparing TXA administration with no TXA in patients receiving at least 1 unit of packed red blood cells. A subgroup of patients receiving massive transfusion (≥10 units of packed red blood cells) was also examined. Univariate and multivariate regression analyses were used to identify parameters associated with survival. Kaplan-Meier life tables were used to report survival.
*SETTING:*

A Role 3 Echelon surgical hospital in southern Afghanistan.

*PATIENTS:*

A total of 896 consecutive admissions with combat injury, of which 293 received TXA, were identified from prospectively collected UK and US trauma registries.

*MAIN OUTCOME MEASURES:*

Mortality at 24 hours, 48 hours, and 30 days as well as the influence of TXA administration on postoperative coagulopathy and the rate of thromboembolic complications.

*RESULTS:*

The TXA group had lower unadjusted mortality than the no-TXA group (17.4% vs 23.9%, respectively; P = .03) despite being more severely injured (mean [SD] Injury Severity Score, 25.2 [16.6] vs 22.5 [18.5], respectively; P < .001). This benefit was greatest in the group of patients who received massive transfusion (14.4% vs 28.1%, respectively; P = .004), where TXA was also independently associated with survival (odds ratio = 7.228; 95% CI, 3.016-17.322) and less coagulopathy (P = .003).

*CONCLUSIONS:*

The use of TXA with blood component-based resuscitation following combat injury results in improved measures of coagulopathy and survival, a benefit that is most prominent in patients requiring massive transfusion. Treatment with TXA should be implemented into clinical practice as part of a resuscitation strategy following severe wartime injury and hemorrhage.


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## goon175 (Jan 20, 2013)

That was great, thanks! So basically the down and dirty is that if you have massive bleeding and can be expected to be picked up relatively soon, use it. Is that the gist of it?


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## bublik (Jan 20, 2013)

Yes, and I'd expect that giving it early - regardless of pick up time - would be optimal over not giving it.


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## surgicalcric (Jan 20, 2013)

MEDEVAC times arent a factor Goon but time of wounding to administration should be within 3 hours.  After this point the value added decreases to the point that it is nearly a waste to give it.

The data from the various studies looks very promising and its nice to see USASOC getting ahead of the power curve.  It is a shame it has taken this long to get it into medics hands but better a lil slow than never.    

I know one SF medic who is thankful for its use at the Role 3 in Tarin Kowt, Astan. 

Hopefully we will have it all across USASOC shortly.


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## amlove21 (Jan 20, 2013)

bublik said:


> Yes, and I'd expect that giving it early - regardless of pick up time - would be optimal over not giving it.


Like Crip said- within three hours. In the TCCC/combat environment, TXA is administered to a viable patient likely to receive mass transfusion at higher level care. The CRASH-2 and MATTERs were pretty conclusive on it's efficacy inside of those paramaters. 

On a side note- TXA is cheap (about $100 a gram, which is one dose), stable, resistent to temp changes- it's all around an awesome drug. Every single medic should have it in his bag and know how/when to administer it. The more combat time and data points TXA sees, the greater it's use should become. 



goon175 said:


> That was great, thanks! So basically the down and dirty is that if you have massive bleeding and can be expected to be picked up relatively soon, use it. Is that the gist of it?


 
Just a clean upnote- it's not the bleeding we are worried about, it's the likelyhood of mass transfusion later. And the term "viable patient" should factor big. It's not a magic "stop all bleeding" drug. If we stop the body from breaking down these little "microclots" and larger hole pluggers, when the guys at the CSH or FST or wherever start dropping units of blood and components, the patient will be able to handle the extra fluid without leaking everywhere. 

Our career field added TXA as soon as it hit the TMEP's/TCCC board. Can't say enough about it, great tool to have.


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## policemedic (Jan 20, 2013)

There's more good info here.

To supplement bublik, I've attached the MATTERs study for your reading pleasure. If any verified member wants the .ppt slides, PM me.


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## goon175 (Jan 20, 2013)

Awesome, thanks for the explanation guys, it is much appreciated. I'm "out of the game" right now, and do what I can to stay on top of stuff like this for when I am back at it again.


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