Tag Archives | tranexamic acid

Update: Tranexamic Acid in Children

The Royal College of Paediatrics and Child Health have recently published an Evidence Statement, regarding the use of tranexamic acid (TXA) in children who have suffered traumatic injuries. The guidance recognises the strong evidence for the use of TXA in the context of trauma in adults.  However, a degree of caution needs to be exercised in the extrapolation of this to the treatment of paediatric injuries.

The following key points have been stated in the guidance:

  • Tranexamic acid reduces mortality in adult trauma
  • Early administration is vital for efficacy
  • Due to the lack of published data on the use of tranexamic acid in paediatric patients who have undergone major trauma there is no evidence for a specific dose in this situation
  • The RCPCH and NPPG Medicines Committee recommend a pragmatic dosage schedule – 15mg/kg tranexamic acid loading dose (max 1g) over 10 minutes followed by 2mg/kg per hour

RCPCHThe full guidance can be downloaded here from the RCPCH website.

 

 

 

 

 

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Tranexamic Acid update

red_blood_cellsSince the CRASH2 trial was published in 2010, there has been a huge amount of work to ascertain how best to deliver tranexamic acid practically, particularly in the prehospital environment.

The benefits of tranexamic acid almost seemed too good to be true.  It’s cheap, easy to carry, has been used for decades within hospital and GP settings – and seems to offer absolute benefits in promoting haemostasis, with no side effects.  It also fits very well into the ‘damage limitation’ approach that has changed much of prehospital trauma care over the last few years.  In addition, military experience, particularly from Afghanistan, has accelerated the availability of high quality practical data on its use in challenging environments.

Now, there is some solid and pragmatic advice on the administration of tranexamic acid, including a Cochrane review which has been published in December last year:

>> Blood-clot promoting drugs for acute traumatic injury

It appears that it is now at a point that many practitioners can and should be considering its use.  Especially for areas where transfer to a surgical or major trauma unit is likely to be delayed – such as rural and remote areas of Scotland – it could offer vital life-saving benefits of reduced blood loss and extended survival times in the context of major trauma.

Administration is relatively straightforward.  Where there is evidence of a ‘positive primary survey’ – i.e. where pulse, blood pressure/capillary refill time or respiration rate are impaired due to suspected haemorrhage, resulting from trauma in the last 3 hours, the following treatment is suggested:

  • Inject two 500mg vials (1g) of tranexamic acid into a 100mL bag of normal saline.  Give this IV over 10-20 minutes (loading dose).
  • Inject two 500mg vials (1g) of tranexamic acid into a 500mL bag of normal saline.  Give this IV over 8 hours (maintenance dose).

Commonly, where transfer to hospital or extrication takes less than 30 minutes, the maintenance dose can be more safely given once the patient is in a facility that can provide an IV pump to give this over a more exact time.

httpv://www.youtube.com/watch?v=7oekncvAXGs

 

Crash 3 Trial

The investigators are now busy conducting the Crash 3 trial which will look at the effects of tranexamic acid specifically on traumatic brain injury.  They’ve produced a video explaining the new trial procedure – which also highlights some of the key points of using tranexamic acid above.

httpv://www.youtube.com/watch?v=7jdjSAiiCmc

 

 

 

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Tranexamic Acid in Major Haemorrhage

The CRASH-2 trial was published in the Lancet in June 2010, and presents strong evidence for the use of tranexamic to reduce haemorrhage in the context of major trauma.  The fact that tranexamic is cheap, seems to be safe, and is easy to obtain & administer makes it an attractive drug for general use. The study used a 1g IV bolus over 10 minutes (within 8 hours of injury), followed by 1g IV infusion over eight hours.

It would seem that tranexamic acid may have the particular potential to benefit patients who have suffered major trauma in rural areas, where the logistics of transfer/retrieval can result in prolonged time to definitive surgical care.  Permissive hypotension is standard practice, with a similar rationale to avoid destabilising clot formation that has already occurred.  The question now is whether it can be used routinely in rural community hospitals, or even by emergency responders such as  BASICS GPs, or is there a need to wait until more specific guidance?  In a bid to gauge its current use, a discussion has been start on the RuralGPNetwork, and any relevant updates will be posted here.  In the meantime comments are welcomed below too.

  • The original article (PDF;  The Lancet).  CRASH-2 trial collaborators. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with signifi cant  haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet 2010; published online June 15. DOI:10.1016/S0140-6736(10)60835-5.
  • The associated editorial (PDF; The Lancet) by J Levy.

Dr Levy has also issued a YouTube video on this paper:

httpv://www.youtube.com/watch?v=YXPU_MEd5vg

… and The Lancet has recorded its press conference when the paper was published: you can listen to it here.

[podcast]http://download.thelancet.com/flatcontentassets/audio/lancet/2010/crash2.mp3[/podcast]

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