Page 38 - JSOM Fall 2020

The Use of Tranexamic Acid in Tactical Combat Casualty Care

TCCC Proposed Change 20-02

Brendon Drew, DO *; Jonathan Auten, DO ; Andre Cap, MD, PhD ;
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Travis Deaton, MD ; Benjamin Donham, MD ; Warren Dorlac, MD ;
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Joseph DuBose, MD, FACS, FCCM ; Andrew D. Fisher, MD, PA-C ; Alan J. Ginn ;
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James Hancock, MD ; John B. Holcomb, MD ; John Knight, MD ; Ryan Knight, MD ;
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Albert “Ken” Koerner, MD ; Lanny Littlejohn, MD ; Matthew J. Martin, MD ;
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John Morey ; Jonathan Morrison, MD ; Martin Schreiber, MD ;
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Philip C. Spinella, MD, FCCM ; Benjamin Walrath, MPH, MD ; Frank Butler, MD 22
ABSTRACT
The literature continues to provide strong support for the – Should a TBI Indication Be Added to the TXA Recommen-
early use of tranexamic acid (TXA) in severely injured trauma dations in the TCCC Guidelines and the Dose Increased to
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patients. Questions persist, however, regarding the optimal 2 Grams?
medical and tactical/logistical use, timing, and dose of this – Is There a Need to Reinforce the Timely Administration of
medication, both from the published TXA literature and from TXA When Indicated?
the TCCC user community. The use of TXA has been explored – Is a Second Dose of TXA Needed to Improve Outcomes
outside of trauma, new dosing strategies have been pursued, When Used for Bleeding Trauma Patients?
and expansion of retrospective use data has grown as well. – Is TXA Effective When Administered via the IM route to
These questions emphasize the need for a reexamination of Bleeding Trauma Patients?
TXA by the CoTCCC. The most significant updates to the – Is TXA Effective When Administered via the IO route to
TCCC Guidelines are (i) including significant traumatic brain Bleeding Trauma Patients?
injury (TBI) as an indication for TXA, (ii) changing the dosing – Can TXA Be Safely Given as a Slow (1-minute) IV Push
protocol to a single 2g IV/IO administration, and (iii) recom- Rather Than over 10 minutes?
mending TXA administration via slow IV/IO push. – Can TXA Be Given in the Same IV/IO Line as Blood/
Blood Products?
Keywords: TXA; tranexamic acid; hemorrhage; hemostatics; – Should the Second Dose of TXA Be Administered If More
antifibrinolytics; hemorrhagic shock; traumatic brain injury; Than 3 Hours Have Elapsed Since the Time of Wounding?
traumatic injury – What Is “Initial Fluid Resuscitation?” as Mentioned in the
TCCC Guidelines with Respect to TXA? And when does
it end?
– Is There a Need for a Second Dose of TXA to be Adminis-
Proximate Reason for This Proposed Change tered as Part of TCCC, Given the Discussion of the Phar-
Since the publication of the CRASH-2 and MATTERs studies, macokinetics of TXA Mentioned Above?
the medical literature regarding the use of TXA has grown ex- – And – If a Second dose of TXA Is Needed, Should the Sec-
ponentially. Initially a drug developed to treat menorrhagia and ond Dose Be Given Like the First?
subsequently adopted for use in cardiac surgery and trauma, it – Should the Dose of TXA be Modified in the Presence of
is now used in orthopedic surgery, 2–25 spine surgery, 26–30 plas- Ongoing Hemorrhage?
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tic surgery, 31,32 ophthalmology, otolaryn gology, 34,35 gastroen- – Can TXA Be Administered Through the Same Line as
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terology, maxillofacial surgery, 37–39 pe di atric trauma, 40–42 and Hextend?
post-partum hemorrhage. 43 – If Removed from Glass Vials in Preparation for Adminis-
tration, How Long can TXA be Kept in a Syringe?
Recently, evidence has been obtained from two randomized, – What Is the Current State of Evidence that TXA Causes
controlled trials studying the use of TXA in trauma patients an Increase in the Risk of Deep Venous Thrombosis and
with TBI. The results from both the international CRASH-3 Pulmonary Embolism?
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Trial, and a completed US trial with novel dosing strategy,
require consideration of TXA for this indication as well.
Background
The TCCC change team working on this proposed change Updating the TCCC TXA Dosing Protocol.
identified a number of specific questions that needed to be ad- Feedback from the field reveals that the current administration
dressed in this review. protocols are logistically burdensome in TCCC and may be
*Correspondence email and affiliations are given on page 42.

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