Vol 7, No 1 (2022)
Review paper
Published online: 2022-03-18

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Tranexamic acid use in emergency medicine

Mahdi Al-Jeabory12, Wladyslaw Gawel2, Aleksandra Gasecka3, Lukasz Szarpak145, Wojciech Wieczorek16
Disaster Emerg Med J 2022;7(1):47-51.

Abstract

The most common cause of potentially preventable trauma deaths is hemorrhage. Therefore, it is crucial to understand the mechanisms regulating bleeding and clotting. The physiological mechanisms that control the coagulation process are called the coagulation cascade. In this study, we analyzed the medical literature for published articles on the use of TXA for bleeding. The MEDLINE electronic database was searched for. The keywords we have used were: “tranexamic acid”, “bleeding”, “hemorrhage”, “treatment”, “prevention”, “patient blood management”, “anti-fibrinolytic”, “surgery”, “surgery”, “trauma”, “injury” and “traumatic brain injury”. When managing the traumatic patient, time is of the essence and the same holds true for the TXA application. The largest study regarding the use of TXA in the emergency medicine CRASH-2 found that the administration of TXA within 3 hours following injury significantly reduces the mortality and that every 15-min delay in administering TXA results in increased bleeding and decreased survival by 10%, offering no benefit if administered after 3 hours. In summary, TXA is a safe and reliable agent which greatly increases the survival rate in traumatic patients suffering blood loss, reducing mortality while being safe.

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References

  1. Kalkwarf KJ, Drake SA, Yang Y, et al. Bleeding to death in a big city: An analysis of all trauma deaths from hemorrhage in a metropolitan area during 1 year. J Trauma Acute Care Surg. 2020; 89(4): 716–722.
  2. Al-Jeabory M, Szarpak L, Attila K, et al. Efficacy and Safety of Tranexamic Acid in Emergency Trauma: A Systematic Review and Meta-Analysis. J Clin Med. 2021; 10(5).
  3. Al-Jeabory M, Szarpak L, Rafique Z, et al. Place of tranexamic acid in traumatic brain injury: a systematic review and meta-analysis of randomized controlled trials. Disast Emerg Med J. 2021; 6(4): 155–163.
  4. Green D. Coagulation cascade. Hemodial Int. 2006; 10 Suppl 2: S2–S4.
  5. Heemskerk JW, Bevers EM, Lindhout T. Platelet activation and blood coagulation. Thromb Haemost. 2002; 88(2): 186-193.
  6. Jin J, Daniel JL, Kunapuli SP, et al. Mechanisms of platelet activation and inhibition. Hematol Oncol Clin North Am. 1990; 4(1): 1–26.
  7. Palta S, Saroa R, Palta A. Overview of the coagulation system. Indian J Anaesth. 2014; 58(5): 515–523.
  8. Cesarman-Maus G, Hajjar KA. Molecular mechanisms of fibrinolysis. Br J Haematol. 2005; 129(3): 307–321.
  9. Bannish BE, Chernysh IN, Keener JP, et al. Molecular and Physical Mechanisms of Fibrinolysis and Thrombolysis from Mathematical Modeling and Experiments. Sci Rep. 2017; 7(1): 6914.
  10. Swedberg JE, Harris JM. Natural and engineered plasmin inhibitors: applications and design strategies. Chembiochem. 2012; 13(3): 336–348.
  11. Wardrop D, Estcourt LJ, Brunskill SJ, et al. Antifibrinolytics (lysine analogues) for the prevention of bleeding in patients with haematological disorders. Cochrane Database Syst Rev. 2013(7): CD009733.
  12. Mannucci PM. Hemostatic drugs. N Engl J Med. 1998; 339(4): 245–253.
  13. Roberts I, Edwards P, Prieto D, et al. Tranexamic acid in bleeding trauma patients: an exploration of benefits and harms. Trials. 2017; 18(1): 48.
  14. Boer C, Meesters MI, Milojevic M, et al. Task Force on Patient Blood Management for Adult Cardiac Surgery of the European Association for Cardio-Thoracic Surgery (EACTS) and the European Association of Cardiothoracic Anaesthesiology (EACTA). 2017 EACTS/EACTA Guidelines on patient blood management for adult cardiac surgery. J Cardiothorac Vasc Anesth. 2018; 32(1): 88–120.
  15. Kauvar DS, Lefering R, Wade CE. Impact of hemorrhage on trauma outcome: an overview of epidemiology, clinical presentations, and therapeutic considerations. J Trauma. 2006; 60(6 Suppl): S3–11.
  16. Brohi K, Singh J, Heron M, et al. Acute traumatic coagulopathy. J Trauma. 2003; 54(6): 1127–1130.
  17. Spahn DR, Rossaint R. Coagulopathy and blood component transfusion in trauma. Br J Anaesth. 2005; 95(2): 130–139.
  18. Gatate Y, Masaki N, Sato A, et al. Tranexamic Acid Controlled Chronic Disseminated Intravascular Coagulation Associated with Aortic Dissection and Patent False Lumen for Three Years. Intern Med. 2017; 56(8): 925–929.
  19. Gando S, Wada H, Thachil J, et al. Scientific and Standardization Committee on DIC of the International Society on Thrombosis and Haemostasis (ISTH). Differentiating disseminated intravascular coagulation (DIC) with the fibrinolytic phenotype from coagulopathy of trauma and acute coagulopathy of trauma-shock (COT/ACOTS). J Thromb Haemost. 2013; 11(5): 826–835.
  20. Ramos C, Moore E, Silliman C, et al. Tranexamic acid accelerates the enzymatic phase of coagulation in trauma patients. Journal of the American College of Surgeons. 2013; 217(3): S136–S137.
  21. Zirk M, Zinser M, Buller J, et al. Supportive topical tranexamic acid application for hemostasis in oral bleeding events - Retrospective cohort study of 542 patients. J Craniomaxillofac Surg. 2018; 46(6): 932–936.
  22. Alaifan T, Alenazy A, Xiang Wang D, et al. Tranexamic acid in cardiac surgery: a systematic review and meta-analysis (protocol). BMJ Open. 2019; 9(9): e028585.
  23. Cap AP, Baer DG, Orman JA, et al. Tranexamic acid for trauma patients: a critical review of the literature. J Trauma. 2011; 71(1 Suppl): S9–14.
  24. Callender ST, Warner GT, Cope E. Treatment of menorrhagia with tranexamic acid. A double-blind trial. Br Med J. 1970; 4(5729): 214–216.
  25. Chauncey JM, Wieters JS. Tranexamic Acid. [Updated 2021 Jul 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK532909/.
  26. Al-Jeabory M, Gasecka A, Wieczorek W, et al. Efficacy and safety of tranexamic acid in pediatric trauma patients: Evidence from meta-analysis. Am J Emerg Med. 2021; 49: 404–405.
  27. Chornenki NL, Um KJ, Mendoza PA, et al. Risk of venous and arterial thrombosis in non-surgical patients receiving systemic tranexamic acid: A systematic review and meta-analysis. Thromb Res. 2019; 179: 81–86.
  28. WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet. 2017; 389(10084): 2105–2116.
  29. Roberts I, Shakur H, Coats T, et al. The CRASH-2 trial: a randomised controlled trial and economic evaluation of the effects of tranexamic acid on death, vascular occlusive events and transfusion requirement in bleeding trauma patients. Health Technol Assess. 2013; 17(10): 1–79.
  30. Zufferey PJ, Miquet M, Quenet S, et al. tranexamic acid in hip-fracture surgery (THIF) study. Tranexamic acid in hip fracture surgery: a randomized controlled trial. Br J Anaesth. 2010; 104(1): 23–30.
  31. Evensen A, Anderson JM, Fontaine P. Postpartum Hemorrhage: Prevention and Treatment. Am Fam Physician. 2017; 95(7): 442–449.
  32. Sentilhes L, Winer N, Azria E, et al. Groupe de Recherche en Obstétrique et Gynécologie. Tranexamic Acid for the Prevention of Blood Loss after Vaginal Delivery. N Engl J Med. 2018; 379(8): 731–742.
  33. Gilad O, Merlob P, Stahl B, et al. Outcome following tranexamic acid exposure during breastfeeding. Breastfeed Med. 2014; 9(8): 407–410.
  34. Roberts I, Shakur H, Afolabi A, et al. CRASH-2 collaborators. The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomised controlled trial. Lancet. 2011; 377(9771): 1096–101, 1101.e1.
  35. Roberts I, Shakur H, Ker K, et al. CRASH-2 Trial collaborators, CRASH-2 Trial collaborators. Antifibrinolytic drugs for acute traumatic injury. Cochrane Database Syst Rev. 2011; 12(1): CD004896.
  36. Johnson WD, Griswold DP. Traumatic brain injury: a global challenge. Lancet Neurol. 2017; 16(12): 949–950.
  37. CRASH-3 Intracranial Bleeding Mechanistic Study Collaborators. Tranexamic acid in traumatic brain injury: an explanatory study nested within the CRASH-3 trial. Eur J Trauma Emerg Surg. 2021; 47(1): 261–268.
  38. AbdelFatah M. Prognosis of acute subdural hematoma greater than 10 mm in thickness in head injury patients with an extension or no motor response to pain after resuscitation. Egyptian Journal of Neurosurgery. 2019; 34(1).
  39. Jokar A, Ahmadi K, Salehi T, et al. The effect of tranexamic acid in traumatic brain injury: A randomized controlled trial. Chin J Traumatol. 2017; 20(1): 49–51.
  40. Fakharian E, Abedzadeh-Kalahroudi M, Atoof F. Effect of Tranexamic Acid on Prevention of Hemorrhagic Mass Growth in Patients with Traumatic Brain Injury. World Neurosurg. 2018; 109: e748–e753.
  41. Mousavinejad M, Mozafari J, Ilkhchi RB, et al. Intravenous Tranexamic Acid for Brain Contusion with Intraparenchymal Hemorrhage: Randomized, Double-Blind, Placebo-Controlled Trial. Rev Recent Clin Trials. 2020; 15(1): 70–75.
  42. Kadar A, Chechik O, Steinberg E, et al. Predicting the need for blood transfusion in patients with hip fractures. Int Orthop. 2013; 37(4): 693–700.
  43. Lee C, Freeman R, Edmondson M, et al. The efficacy of tranexamic acid in hip hemiarthroplasty surgery: an observational cohort study. Injury. 2015; 46(10): 1978–1982.
  44. Goodwin T, Moore K, Pasley J, et al. From the battlefield to main street: Tourniquet acceptance, use, and translation from the military to civilian settings. Journal of Trauma and Acute Care Surgery. 2019; 87(1S): S35–S39.
  45. Eastridge BJ, Mabry RL, Seguin P, et al. Death on the battlefield (2001-2011): implications for the future of combat casualty care. J Trauma Acute Care Surg. 2012; 73(6 Suppl 5): S431–S437.
  46. Butler FK, Blackbourne LH. Battlefield trauma care then and now: a decade of Tactical Combat Casualty Care. J Trauma Acute Care Surg. 2012; 73(6 Suppl 5): S395–S402.
  47. Morrison JJ, Dubose JJ, Rasmussen TE, et al. Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study. Arch Surg. 2012; 147(2): 113–119.
  48. Walker PF, Bozzay JD, Johnston LR, et al. Outcomes of tranexamic acid administration in military trauma patients with intracranial hemorrhage: a cohort study. BMC Emerg Med. 2020; 20(1): 39.
  49. Johnston LR, Rodriguez CJ, Elster EA, et al. Evaluation of Military Use of Tranexamic Acid and Associated Thromboembolic Events. JAMA Surg. 2018; 153(2): 169–175.
  50. Drew B, Auten JD, Cap AP, et al. The Use of Tranexamic Acid in Tactical Combat Casualty Care: TCCC Proposed Change 20-02. J Spec Oper Med. 2020; 20(3): 36–43.
  51. Vujkovac B, Sabovic M. Treatment of subdural and intracerebral haematomas in a haemodialysis patient with tranexamic acid. Nephrol Dial Transplant. 2000; 15(1): 107–109.
  52. Sabovic M, Lavre J, Vujkovac B. Tranexamic acid is beneficial as adjunctive therapy in treating major upper gastrointestinal bleeding in dialysis patients. Nephrol Dial Transplant. 2003; 18(7): 1388–1391.
  53. Koo JR, Lee YK, Kim YS, et al. Acute renal cortical necrosis caused by an antifibrinolytic drug (tranexamic acid). Nephrol Dial Transplant. 1999; 14(3): 750–752.
  54. Foster GR, Carmichael DJ, Kermode A, et al. Extensive crescent formation with antifibrinolytic therapy in a case of diffuse endocapillary glomerulonephritis. Nephrol Dial Transplant. 1990; 5(2): 152–154.
  55. Sabbag OD, Abdel MP, Amundson AW, et al. Tranexamic Acid Was Safe in Arthroplasty Patients With a History of Venous Thromboembolism: A Matched Outcome Study. J Arthroplasty. 2017; 32(9S): S246–S250.
  56. Peng H, Wang L, Weng X, et al. Effect of tranexamic acid on symptomatic venous thromboembolism in patients undergoing primary total knee arthroplasty. Arch Med Sci. 2020; 16(3): 603–612.