Prehospital Guidelines for the use of Tranexamic Acid (TXA)
Dr. James Winslow
EMS in North Carolina continues to progress. Systems continue to implement more first responder naloxone and epinephrine programs. The newly formed North Carolina Medical Board EMS Advisory group continues to review EMS scope of practice in North Carolina. The advisory group’s current aims include insuring that the EMS scope of practice matches national guidelines and also meets the specific needs of North Carolina. Many EMS agencies have been adding TXA to their formulary of drugs. I wanted to summarize a recent guidance document on the use of Tranexamic acid in the prehospital environment. (Tranexamic acid is a medication used to treat or prevent excessive blood loss from trauma, surgery, and in various medical conditions.)
The guidance document on the use of Tranexamic Acid (TXA) has recently been created by the American College of Surgeons-Committee on Trauma, the American College of Emergency Physicians and the National Association of EMS Physicians. The document summarizes the available evidence looking at the Prehospital use of TXA and also gives guidance on its use. Since TXA is increasingly being used by EMS agencies I thought it was important to summarize this document.
Perhaps the most important point about the guidance document is that it gives no guidance on whether or not TXA should be given in the Prehospital environment. The authors state that there is not enough evidence to say that it should or should not be given. There are several studies now being carried out which, when completed, will hopefully provide more evidence to guide medical directors and EMS agencies. There is evidence to support the use of TXA in the hospital. The CRASH-2 study found that there was a 1.5 percent decrease in all causes of deaths in trauma patients who received TXA. The CRASH-2 study is the largest study to date looking at the use of TXA for trauma patients. CRASH-2 also seemed to show the earlier TXA was given the better. If it was given more than three hours after injury then mortality seemed to increase.
The document makes several additional recommendations if EMS chooses to give TXA.
- System integration is very important.
The EMS agency and receiving facility should have an agreed upon protocol. The receiving facility should also agree to give the second dose of TXA, which involves an eight-hour infusion. There should also be a standard hand off procedure to ensure that the receiving facility knows that the TXA was given
- TXA should only be given to patients who have a noncompressible severe hemorrhage that is not amenable to tourniquet use.
TXA should only be given to trauma patients who will need a massive transfusion of blood products or the TXA could cause blood-clotting complications. The authors suggest that heart rate should be more than 120 and the systolic BP less than 90 if TXA is to be given.
- All patients who receive TXA should be transported to a Level one or Level two trauma center.
This makes sense since these patients will be among the sickest category of trauma patients.
- There must be a robust monitoring system.
Because there is limited evidence on whether TXA should be used in the Prehospital environment, it is very important for EMS and the receiving hospital to monitor its use. All cases should be reviewed for appropriateness of use and for any complications. Protocols should be adjusted accordingly.
- Use caution in cases of known anticoagulation.
There does not appear to be any data on whether or not TXA can cause issues in patients on Coumadin who also must receive other agents at the hospital to reverse the anticoagulation caused by Coumadin. Because of this the document recommends that medical control be contacted prior to giving TXA to patients taking Coumadin.
- It is not recommended in pediatric patients.
There is very limited evidence looking at the use of TXA in pediatrics. In the pediatric surgery literature there have been cases of children having seizures after receiving TXA. For this reason the authors say that TXA should not be given to children.
Dr. Winslow graduated from Emergency Medicine residency from UNC-Chapel Hill in 2002 and completed his EMS Fellowship in 2003. He has worked at Baptist Hospital in Winston-Salem for the past 11 years. He was appointed as the Medical Director of the NC Office of EMS in 2011. This document contains all protocol, procedures, and policies for all EMS agencies in North Carolina.“Guidance Document for the Prehospital Use of Tranexamic Acid in Injured Patients,” Prehospital Emergency Care, 2016 (Early Online)http://www.tandfonline.com/doi/full/10.3109/10903127.2016.1142628
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