Page 87 - 2020 JSOM Winter

Case Series on 2g Tranexamic Acid Flush
From the 75th Ranger Regiment Casualty Database

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Christopher Androski, MD *; William Bianchi, DO, MSc ; Douglas L. Robinson, DO, MS ;
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Gregory J. Zarow, PhD ; Charles H. Moore, MD ; Travis Deaton, MD ;
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Brendon Drew, DO ; Simon Gonzalez ; Ryan M. Knight, MD 9

ABSTRACT
Early tranexamic acid (TXA) administration for resuscitation for heavy bleeding in medical domains, ranging from dentistry
of critically injured warfighters provides a mortality benefit. and postpartum obstetrics to surgery and trauma. 4,6 –9
The 2019 Tactical Combat Casualty Care (TCCC) recommen-
dations of a 1g drip over 10 minutes, followed by 1g drip over Empirical evidence supports the efficacy of TXA. For ex-
8 hours, is intended to limit potential TXA side effects, in- ample, the Clinical Randomization of an Antifibrinolytic in
cluding hypotension, seizures, and anaphylaxis. However, this Significant Hemorrhage 2 (CRASH-2) randomized place-
slow and cumbersome TXA infusion protocol is difficult to bo-controlled trial of 20,211 traumatically injured individu-
execute in the tactical care environment. Additionally, the side als at 274 hospitals in 40 countries found that TXA reduced
effect cautions derive from studies of elderly or cardiothoracic all-cause deaths and risk of death due to bleeding when TXA
surgery patients, not young healthy warfighters. Therefore, was given within 3 hours of injury. Further, the CRASH-2
the 75th Ranger Regiment developed and implemented a 2g trial found no significant differences between intervention
intravenous or intraosseous (IV/IO) TXA flush protocol. We and placebo groups in vascular occlusive events and con-
report on the first six cases of this protocol in the history of cluded that TXA should be considered in treating bleeding
the Regiment. After-action reports (AARs) revealed no inci- trauma patients. Most recently, the CRASH-3 trial demon-
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dences of post-TXA hypotension, seizures, or anaphylaxis. strated mortality benefit in patients with mild-to-moderate
Combined, the results of this case series are encouraging and traumatic brain injury, with the greatest benefit observed with
provide a foundation for larger studies to fully determine the early TXA administration. 6
safety of the novel 2g IV/IO TXA flush protocol toward pre-
serving the lives of traumatically injured warfighters. The retrospective Military Application of Tranexamic Acid in
Trauma Emergency Resuscitation (MATTERs) Study, which
Keywords: tranexamic acid; TXA; TXA flush; TXA intraosse- specifically evaluated warfighters with traumatic battlefield
ous; TXA protocol; Tactical Combat Casualty Care (TCCC) injuries, further demonstrated a mortality benefit with TXA
administration. Importantly, this benefit was most evident in
patients requiring massive transfusion. 10
Introduction Per Tactical Field Care and Tactical Evacuation Care phases
Hemorrhage continues to be the leading cause of death from of Tactical Combat Casualty Care (TCCC) guidelines, TXA is
potentially survivable battlefield injuries. Accordingly, the recommended for all casualties who require (or are expected
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Department of Defense (DoD) is focused on improving the to require) significant blood transfusion, have signs of hemor-
care of warfighters with active exsanguination. To assist in rhagic shock, sustain penetrating torso trauma, sustain one or
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preserving life on the battlefield, TXA is often used because of more amputations, and/or have persistent and severe bleed-
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its proven mortality benefit. 4 ing. Consistent with civilian hospital protocols, the 2019
TCCC protocols recommend a dose of 1g TXA dripped over
TXA is an antifibrinolytic agent that slows hemorrhage by in- 10 minutes, followed by an additional 1g dose dripped over
hibiting clot lysis. First characterized in 1962, this synthetic an unspecified amount of time, but presumably over 8 hours
lysine derivative inhibits fibrinolysis by blocking the lysine site (in accordance with previous studied protocols). 2,4,6,10 The
on plasminogen. TXA use has become an accepted treatment reason for this slow infusion rate is to avoid rapid rises in
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*Correspondence to chris05588@gmail.com
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1 LT Androski is affiliated with the Combat Trauma Research Group West, USMC School of Infantry West, Camp Pendleton, CA. LT Bianchi
is the director of the Combat Trauma Research Group West and an emergency medicine physician at the Naval Medical Center San Diego, San
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Diego, CA. CPT Robinson is a battalion surgeon for the 75th Ranger Regiment. Dr Zarow is the Emergency Statistician, Idyllwild, Califor-
nia, and the senior scientist for Combat Trauma Research Group West at Naval Medical Center San Diego, San Diego, CA. MAJ Moore is a
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physician affiliated with the 75th Ranger Regiment. CDR Deaton is an emergency medicine physician and Division Surgeon for the 1st Marine
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Division in Camp Pendleton, CA. CAPT Drew is an emergency medicine physician, force surgeon for the 1st Marine Expeditionary Force, chair
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of the JTS Committee on Tactical Combat Casualty Care, and the Navy emergency medicine specialty leader. MSG Gonzalez is an advanced
tactical paramedic and regimental senior enlisted medical advisor in the 75th Ranger Regiment. LTC Knight is an emergency medicine physician
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and regimental surgeon for the 75th Ranger Regiment.
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