Page 161 - JSOM Spring 2020

CDR Drew talked about the ability to give TXA IM but Current dosing:
stated that we are not there yet but hopefully in the future • First dose: 1g over 10 minutes
this will be a possibility. One problem with giving it IM • Second dose: 1g over 8 hours
is you do not get peak serum viability for 40–60 minutes
compared to IV administration with onset within five min- Proposed dosing:
utes and as we all know the sooner you give TXA the bet- • 2g slow IV or IO push as soon as possible but NOT
ter. There are some pig studies that will be coming out and later than 3 hours after injury (for trauma and TBI).
one that is being conducted by an Air Force trauma fellow Current dosing to women in post-partum bleeding:
that is showing the viability of giving high dose of TXA to • First time a current dosing protocol that follows what
an animal or human in hemorrhagic shock. Currently there we are proposing.
are no studies that show giving TXA IM is a viable option.
Q7: What if you give TXA to someone with a mild TBI?
The subject of giving TXA IO is more of a “why not” A7: That is still something that we are looking into. (The
rather than why because anything you can give IV you CRASH-3 results had not yet been published at the time
should be able to give IO. The Ranger regiment and some of this meeting.)
civilian EMS personnel are giving it IO with no adverse
effects, so we will be recommending giving TXA via IO Q8: What if overuse of TXA?
for TCCC. A8: Dr Mann-Salinas of JTS PI is doing a study/project on
CDR Drew asked if anyone had thoughts on giving IO this matter.
or IM? Q9: What happens if you give it to fast?
Q1: Peak-vs-effective serum A9: In theory you could cause hypotension. In a study
A1: Varied to delayed with human volunteers who were given TXA rapidly, one
patient complained of orthostatic symptoms. There are
There was some discussion on the following question:
no publications with documented clinically relevant hy-
Q2: What if you have a patient with limited access? potension with TXA administration.
A2: Part of our approach was that everyone is going to
be very aggressive in their approach and at the minimum 11. Tourniquet update
will get IO access. However, we need more human data Harold Montgomery, JTS contractor, began with stan-
to show if we can give it IM and get the peak serum level dard disclaimers. Mr Montgomery went over the timeline
up. Our group concluded that we cannot wait 5 years but and decisions points of how the CoTCCC updated the
we need to do a relook in 2 years. IM use is considered. tourniquet recommendations.
Q3: What about intranasal? The CoTCCC voted on the tourniquet change recommen-
A3: Yes, you can give it IN but that is a topical application. dations in April/May time frame and as soon as we ap-
There is no evidence by giving it IN there will be any sys- proved the current tourniquets new and possibly better
temic effect. However, TXA soaked gauze is being used ones have hit the market. The tourniquets that were voted
by Ortho as a hemostatic agent. on were split into two groups: 1) nonpneumatic and 2)
pneumatic.
Q4: Is there a contraindication if you give it IM initially
and then give it IO later? Recommended nonpneumatic tourniquets are:
A4: Not at this time. Many European militaries propose 1. Combat Application Tourniquet (CAT) Generation 6
this now in situations where there is no medical sup- 2. Combat Application Tourniquet (CAT) Generation 7
port. IM TXA with delayed onset is one intervention that 3. SOFTT-Wide
can potentially be pushed to the level of nonmedical 4. Tactical Mechanical Tourniquet (TMT)
personnel. 5. Ratcheting Medical Tourniquet Tactical (RMT-T) or
TX2
Q5: Is there any absorption issues in IM injections if mus- 6. SAM Extremity Tourniquet (SAM-XT)
cle has been exposed to trauma or cold environment?
A5: There are no real studies of muscle beds that have Recommended pneumatic tourniquets are:
been exposed to hemorrhagic shock for TXA and ab- 1. Delphi-EMT
sorption rate. There is a paper coming out soon on this 2. Tactical Pneumatic Tourniquet (TPT2)
subject. *NOTE: The pneumatic tourniquets would be primarily
Q6: Nebulizer? used for tourniquet conversions/replacement once the ca-
A6: Only study he has seen in using TXA via nebulizer is sualty reached a higher level of care but not at POI.
for bronc procedures with biopsies. Mr Montgomery then reviewed the grading criteria that
was used and will be published in the tourniquet change
There are currently three patient populations that get paper that will be released soon.
TXA after they are bleeding: 1) trauma, 2) postpartum
hemorrhage, and 3) epistasis. Everyone else gets TXA Criteria that were established by the working group and
prophylactically. used for this project are:
1. Arterial occlusion (main factor)
CDR Drew then moved onto a subject that has a lot of 2. Speed of application
attention – dosage. He stated the current dosing is based a. 60 seconds or less
off a 1995 cardiovascular surgery literature paper.
b. <90 seconds to complete

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