# Tranexamic Acid use in TCCC



## kaja (Apr 6, 2012)

I hope I don't look to lazy asking questions here instead of doing my own research,but insight of you guys who have personal experience is invaluable for me.

Are you familiar with using TXA during field care or do you know where to find some relevant study regarding it's use in military settings?

Thank you


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## policemedic (Apr 6, 2012)

http://www.nlm.nih.gov/bsd/pmresources.html


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## kaja (Apr 6, 2012)

Yop, found this http://www.ncbi.nlm.nih.gov/pubmed/22006852 , but I'd like to see some case history before reaching ROLE 3, preferably from field (thus asking on use in TCCC). Thanks nonetheless


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## policemedic (Apr 6, 2012)

Kaja, are you aware that the MATTERs study was instrumental in the recent inclusion of TXA into SOF TCCC protocols?  It's well worth reading.


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## kaja (Apr 6, 2012)

To be honest I wasn't. I read through it, and it looks really promising. Maybe I mis-formulated my first post, but I was mainly interested in documented pre-hospital use, it's availability in field and if it's widely used in theatre right now (or just by SOF?).


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## Muppet (Apr 6, 2012)

I never heard of this until now. Learn something new everyday...

F.M.


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## DoctorDoom (Aug 30, 2012)

I trained in trauma with a couple of the authors of that study.  I'll see if I can ping them.


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## Marauder06 (Aug 30, 2012)

Yet another thread where I have absolutely no idea about what is being discussed... ;)


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## amlove21 (Sep 1, 2012)

Marauder06 said:


> Yet another thread where I have absolutely no idea about what is being discussed... ;)


 
Even if you're joking, I'll throw out a laymans term definition of TXA for those that wanna talk about it. Everyone smarter, pile on. 

TXA is an anti-fibronolytic. It stops your body from breaking down clots. While this seems counter-intuitive in trauma (blood clots = our friends for no more bleedy), it actually helps in viable trauma patients with the need for massive blood transfusions. When administered in the first 3 hours after injury pre-hospitally (1gm), the MATTERs study (and some other lesser known studies) have shown that viable patients needed far less whole blood/component blood products than those that did not receive TXA. Another good source for this info is in "War Surgery in Iraq and Afghanistan", notably by the Lt Col ADO of Landstuhl's Regional Med Center. It's a great book for med geeks worldwide. 

When your body is in shock, and you're nearing the "holy shit" point of the lethal triad (coagulopathy, hypothermia, acidosis), TXA helps your body to stop all those little leaks at the cellular level by not allowing your body to break down the clots you have made (the coagulation). That way, when the patient gets blood later, that blood goes into a more solid container, and not a sieve.

Kaja- it was added to the SOF TCCC protocols and algorithms last year, with good result. I know it's been added to our standard load out as a result. 

Yet another example of this 12 years of military conflicts advancing


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## HoosierAnnie (Sep 1, 2012)

How long does the anti-fibrinolytic effect last and is there any danger of a rebound DIC?


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## policemedic (Sep 1, 2012)

tagged for later.


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## amlove21 (Sep 1, 2012)

HoosierAnnie said:


> How long does the anti-fibrinolytic effect last and is there any danger of a rebound DIC?


I would have to check for sure on both; however, I want to say that the effective range is tied to the 3 our window in which it is administered (meant to be 3 hours from injury to surgery). As for rebound DIC- I know that isn't the concern immediately (as we are speaking about borderline viable trauma patients in need of massive blood transfusion, meaning more than 10 units), but that's not to say it isn't/shouldn't be a concern. I would assume it would have to be on some level, although I dont think that the TXA produces such a potent systemic response and assuming that it's effect wouldnt outlast the surgery. Also, we are presuming a pretty high level of coagulopathy as it is, I don't think TXA is as potent as say Factor VII. 

Interesting questions though, I will look it up and talk to some of my docs here.


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## DoctorDoom (Sep 1, 2012)

No DIC, mechanistically it prevents clot breakdown, and with massive transfusion there is little chance of a pro-coagulant state.  In fact, TXA has been used to treat DIC.

Duration for non-trauma uses is about 8 hours between doses, but plasma half life is about 90 mins.


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## chaarsadobeest (Sep 2, 2012)

TXA is not taught as being within the scope of practice for standard Army 68W's, and thus is not even mentioned as an option in any "regular ol' medic" training/literature I'm aware of. The latest TCCC Guidelines include the note: "Per the Assistant Secretary of Defense for Health Affairs memo dated 4 November 2011, use of TXA *outside of fixed medical facilities* is limited to the Special Operations community". Considering how many medics (most actually) work at higher echelons of care (ROLE III, FST, etc.) responsible for a spectrum of interventions, it's surprising that it's absent from both MOS, refresher, and predeployment training/BCT3 (regarding only clinical interventions). Based on the MATTERs study, I'm curious if TXA ends up being included in future skill sets outside of SOF.


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## x SF med (Sep 2, 2012)

DoctorDoom said:


> No DIC, mechanistically it prevents clot breakdown, and with massive transfusion there is little chance of a pro-coagulant state. In fact, TXA has been used to treat DIC.
> 
> Duration for non-trauma uses is about 8 hours between doses, but plasma half life is about 90 mins.


 
doc, any long term hepatic or renal complications due to the disruption of the hemofibral thread dissolution from the prevention of the clot breakdown?


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## DoctorDoom (Sep 11, 2012)

x SF med said:


> doc, any long term hepatic or renal complications due to the disruption of the hemofibral thread dissolution from the prevention of the clot breakdown?


 
First, SERIOUS DISCLAIMER:  I am by no means an expert on the use of TXA and the long term effects after resuscitation.  So what I'm giving you is what I know and recall, having been trained by the authors of the MATTERS study and by the invited critique author, Dr. Kenji Inaba.  _Caveat lector_.

Short answer?  Theoretically, yes, but no one really knows, because there just isn't enough data

Long answer, no long term hepatic or renal complications are known in non-trauma use, but recall that the majority of use has been in clotting disorders, a population where major thrombosis or embolus is not at issue.  Large vessel issues would need to have patients that are already in some type hypercoagulable state, and the TXA then aids clot propagation, which would be statistically quite rare as those patient would not likely be taking TXA.   In terms of small vessel or microthrombosis or emboli, it would likely cause problems, but again not too many patients in that category.  Mechanistically it makes sense that TXA induced, arteriole sited, damage could be a problem, because the plasminogen activation inhibition is more effective in the small vessels, but that's me spitballing.  

The two ways in which renal/hepatic impairment would occur in trauma use would be either in the large vessel obstruction or small vessel.  This is why TXA can only be used in the initial 3 hours of trauma, just as it can only be used in the hemorrhage stage of septic DIC in the fibrinolytic stage.  During that period, the primary necessity is to counter the bleeding.  Mostly the TXA is used to buy time to correct the underlying cause of hemorrhage.  Even in that 3 hour window, the rates of DVT and PE were higher in the treatment group.  After the 3 hour window, bleeding rates actually INCREASED.  Was this because of unknown site of surgically treatable bleeding?  Was this because the TXA increased consumption of transfused coagulation factors, in essence CREATING a DIC like-state (which is why in septic DIC TXA is given with heparin to anticoagulate at the same time)?  No one really knows.  After that period, theoretically, all the TXA would be doing is propagating clot initiated by exposed tissue factor, contributing to MSOF.  But I don't think there's enough data out there for anyone to authoritatively comment on long term hepatic or renal sequelae.  Although I will say hepatic sequealae are rather rare in similar situations, renal complications far more common.

I'm about to go on leave, so I'll get in touch with Kenji and ask him.  And give him shit about volunteering to get Tased for demonstration purposes.  Maybe they need a clinical fellow next year.  Hmmmm...

I don't know if that helped any.


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## x SF med (Sep 11, 2012)

Thanks Doc!  I love the medicalese version of here's what we've seen, but we really don't know yet because it's a new Tx regimen and were still compiling data...  after reading the study, that's exactly what I got from it...  It works, we still need to see if there are long term negatives to the other systems, but the Pts are showing better initial survivability if prorocol can be followed.

It's nice having medical sources that give straight answers, my doctors treat me like an idiot most of the time...


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## DoctorDoom (Sep 11, 2012)

I always try to remember that no matter how much I may know, or think I know, there are people who have forgotten more than I will ever learn.  So keeping in mind that I am usually the idiot in the room helps me give straight answers.


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## x SF med (Sep 11, 2012)

We need a "That's so fucking awesome, it makes AmLove look humble" button for the above post.


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## DoctorDoom (Sep 11, 2012)

x SF med said:


> ...but we really don't know yet because it's a new Tx regimen and were still ...It works, we still need to see if there are long term negatives to the other systems, but the Pts are showing better initial survivability if protocol can be followed.


I think the thought experiment your question targets is useful though, and given the higher incidence of DVT and PE in the treatment group in MATTERS, we have to expect and anticipate higher rates of renal and hepatic thrombotic complications once more people get treated with TXA.  And tease out whether these are clinically significant and whether they are (or not) more significantly increased than what would be expected for combat trauma alone.

So, excellent question.


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## policemedic (Sep 11, 2012)

chaarsadobeest said:


> TXA is not taught as being within the scope of practice for standard Army 68W's, and thus is not even mentioned as an option in any "regular ol' medic" training/literature I'm aware of. The latest TCCC Guidelines include the note: "Per the Assistant Secretary of Defense for Health Affairs memo dated 4 November 2011, use of TXA *outside of fixed medical facilities* is limited to the Special Operations community". Considering how many medics (most actually) work at higher echelons of care (ROLE III, FST, etc.) responsible for a spectrum of interventions, it's surprising that it's absent from both MOS, refresher, and predeployment training/BCT3 (regarding only clinical interventions). Based on the MATTERs study, I'm curious if TXA ends up being included in future skill sets outside of SOF.


 
Please don't get me started on 68W training vs scope of practice.  :-"


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