1. Tranexamic Acid (TXA) Procedure #706 – Hemorrhage Control
Training requirements for State EMS Authority approved Local Optional Scope of Practice
Please see updated protocols in general updates
Procedure #706 – Hemorrhage Control
Protocol #660 – General Trauma
Protocol #661 - Traumatic Cardiac Arrest

2. Objectives Recognition of hemorrhagic shock
Review Tranexamic Acid (TXA)
Indications for use
Action
Contraindications
Dosing
Adverse reactions
Discuss communication/documentation needed for hospital handoff report
Objectives

3. Hemorrhagic Shock

4. Definition: Hemorrhagic SHOCK
Systemic reduction in tissue perfusion below that which is necessary to meet metabolic needs of tissues and organs
Hypoperfusion results in oxygen debt
Hypoperfusion is a time dependent event
Definition: Hemorrhagic SHOCK

5. Classic signs of shock Change in mentation Tachycardia Hypotension
Cool, Clammy skin
Prolonged capillary refill
Narrowed pulse pressure
Classic signs of shock

6. Patients don’t suddenly deteriorate, rather we suddenly notice…
Signs can be difficult to appreciate in early shock and can be missed until the patient is in trouble
Compensatory mechanisms allow significant reductions in circulating blood volume, stroke volume, and cardiac output to occur well before changes in systolic BP
Maintain a high-index of suspicion for occult hemorrhage:
Internal bleeding
Ongoing venous oozing
Open fractures
Bleeding covered by bandages
Epistaxis, vaginal bleeding, GI bleeding
Anticoagulated patients

7. Patients don’t suddenly deteriorate, rather we suddenly notice…
Maintain a high-index of suspicion for occult hemorrhage:
Internal bleeding
Ongoing venous oozing
Open fractures
Bleeding covered by bandages
Epistaxis, vaginal bleeding, GI bleeding
Anticoagulated patients

8. Blood Pressure Systolic BP drop is a late sign
Systolic BP does not fall until:
Adults 30% blood loss
Pediatrics 40-45% blood loss
SBP < 90 mm Hg: mortality approaches 65%
Blood Pressure

9. Fracture-associated blood loss
Humerus 750ml
Tibia 750ml
Femur 1500ml
Pelvis > 3L
Soft tissue trauma can
increase fluid loss with
the activation of inflammatory
response that increase
vascular permeability
Fracture-associated blood loss

10. TXA Mechanism of Action
Injury to blood vessel attracts
Clotting factors
Platelets
Activated platelets begin to trap blood cells

11. TXA Mechanism of Action
Platelet plug is unstable and may not stop all bleeding
Strands of fibrin begin to wind into platelet plug
Fibrin stabilizes plug
Plasmin
Plasmin is present in blood in its inactive form (plasminogen)
Degraded Fibrin
Activated Plasmin degrades Fibrin
Fibrinolysis
Inhibits formation of a stable clot

12. TXA Mechanism of Action
TXA blocks Plasminogen from being converted into activated Plasmin
Plasmin
Reduction of circulating Plasmin:
Less fibrinolysis
Clots are not broken down
More rapid formation of stable clots
Degraded Fibrin

13. Classification & Action
Plasminogen inactivator
Anti-fibrinolytic
Action:
Inhibits conversion of plasminogen to plasmin
Reduces fibrinolysis and clot breakdown
Stabilizes clot formation
Classification & Action

14. Indications Blunt or penetrating traumatic injury with SBP ≤90
Significant blood loss with ongoing bleeding not controlled by direct pressure, hemostatic agents, or tourniquet application
External bleeding should be managed with the methods listed above
TXA is given only if these measures are not successful
Base hospital consultation and orders
Unclear on indications
Other causes of life-threatening hemorrhage
i.e. GI bleeding, vaginal bleeding, ENT post-op, etc

15. Contraindications Patients less than 15 years old
Greater than 3 hours post injury
Isolated Traumatic Brain Injury
Isolated spinal shock
Spinal injury with motor signs and hypotension
Isolated extremity hemorrhage when bleeding has been controlled
TXA should not be used in trauma patients with these isolated injuries
TXA is NOT contraindicated in a trauma patient with hemorrhagic shock AND associated TBI/spinal injuries/ extremity injuries

16. Adverse Reactions Hypotension with rapid IV infusion Chest tightness
Difficulty breathing
Facial flushing
Blurred vision
Nausea/Diarrhea

17. Transport to a Trauma Center
Base contact, consultations, and destination for patients receiving TXA should be a trauma center
SVRMC or MRMC
SLO County Policy #121
Patient will likely require:
Massive Transfusion Protocols (MTP)
Repeat doses of TXA
Surgical interventions
Other interventions

18. References, Clinical Trials
CRASH2 trial (2010):
If given within three hours of injury, TXA reduces the risk of death due to bleeding by about a third
MATTERS trial (2011):
Marked improvement in survival in most severely injured compared to those who did not receive it
7351
CalPAT Trial (2017) California Prehospital Antithrombolytic Trial:
TXA reduced 30-day mortality from 8.3% to 3.6%
Mortality benefit greater in more seriously injured patients
References, Clinical Trials

19. Dosage and Administration
Mixing instructions:
1gm of TXA into 100mL Normal Saline (NS)
Inject through injection port
Use full 100 mL bag of NS, or
Burette filled with 100 mL of NS
Label the bag/burette with the drug name and final concentration
“TXA 1gm in 100mL”

20. Dosage and Administration
Administer 1 gm in 100mL NS IV/IO over 10 min
No repeat
Delivery of a highly specific concentration is not necessary
Dilution and infusion rate are safety measures to mitigate adverse reactions
Use Macrodrip tubing
Infuse >10 min
10 gtts tubing <100 drops/min
15 gtts tubing <150 drops/min

21. Dosage and Administration
TXA may be infused while fluid bolus is being administered for hypotension
Protocol #660 – titrated bolus UP TO 500 mL
Goal is to limit total IV fluids administered while maintaining perfusion
Target is to treat with permissive hypotension
Count TXA volume in total volume of fluids
TXA may be infused through a second IV while titrated fluid bolus is being rapidly administered through primary IV
Use a saline extension so that TXA may be removed once infusion is completed
TXA may be piggybacked on primary line of NS
Piggybacked TXA should be hung higher then the NS so that the TXA infuses first
This will slightly limit the rate of the fluid bolus

22. Communication/Documentation
TXA Local Optional Scope of Practice is approved by the State EMS Authority. Special reporting requirements on TXA use.
Required prehospital documentation:
ePCR
During hospital verbal report/handoff
Document:
Time of injury - confirm <3 hours
Time of administration of TXA
Any adverse reactions
Communication/Documentation

23. TXA Summary TXA works to prevent clot breakdown
Administer to trauma patients, age ≥15 with:
Blunt or penetrating injury with SBP ≤90
Significant blood loss/bleeding not controlled by BLS measures
Use base physician orders for other life-threatening bleeding
Must be started within 3 hours of injury
Receiving hospital must be informed of the injury time and time of 1st dose

24. End of Presentation 2019 General Updates Pain Management and Fentanyl
Please Review:
2019 General Updates
Pain Management and Fentanyl
Vasopressor Doses of Epinephrine