Page 90 - 2020 JSOM Winter

TABLE 1 Pre-TXA and Post-TXA Vital Signs
Case 1 Case 2 Case 3 Case 4 Case 5 Case 6
Vital Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post
HR 90 97 102 100 100 94 125 110 128 120 110 NR
SBP 60 60 80 80 80 80 80 80 80 80 80 NR
RR 14 24 20 20 22 18 20 20 NR NR 22 NR
Spo NR NR 79 NR 98 96 97 95 NR NR 98 NR
2
HR = heart rate; SBP = systolic blood pressure; DBP = diastolic blood pressure; RR = respiratory rate; Spo = blood oxygen saturation; NR =
2
not recorded.
Case 4 FIGURE 2 Time (minutes) from assessment to TXA and from
A member of the Afghanistan Armed Forces sustained multi- TXA to evacuation, with total time from assessment to evacuation
ple fragmentation grenade injuries to the face, left chest, left displayed to the right of the bars.
arm, left leg, and right thigh. On initial assessment by 75th
Ranger Regiment medics, he was found to be alert with ini-
tial vital signs of HR 125, SBP 80, RR 20, and Spo of 97%.
2
Treatment included multiple pressure dressings, a tourniquet
to the left lower extremity, 2 units of fresh whole blood, IV
analgesics, anxiolytics, and antibiotics. The 2g IV TXA flush
was administered within approximately 25 minutes of initial
assessment. The casualty sustained a field care period of 115
minutes prior to evacuation. There was no documented ex-
acerbation of hypotension, seizures, or anaphylaxis between
TXA administration and evacuation.

Case 5
A member of the Afghanistan Armed Forces sustained a small
arms gunshot wound, suspected to originate from enemy 0–108 minutes). Total times from assessment to evacuation av-
ground forces, 10 minutes into a helicopter flight during mis- eraged 58 minutes (SD 51 minutes, range 2 –115 minutes).
sion exfiltration. On initial evaluation, the casualty was alert,
with vital signs of HR 128, SBP 80, and no documented re-
spiratory rate or Spo . Physical exam revealed a single wound Summary of Cases
2
below the sternum. A sternal IO was immediately placed but This case series of six casualties with clear indications for TXA
subsequently failed when flushed with TXA. A right-sided an- administration included two cases of injury from gunshot
tecubital 16-gauge IV was placed and flushed with 2g of TXA, wounds, two from grenades, one from a blast, and one from a
approximately 2 minutes from initial assessment. The exfiltra- blast plus building collapse, all treated in low-light conditions.
tion helicopter was redirected to a receiving medical facility, so Despite varying battlefield complexities, all casualties received
the evacuation time was coded as 0 (zero) because the casualty a 2g TXA flush within the first 45 minutes of assessment, in-
was already in flight. On arrival to the receiving facility, the cluding four by IV access and two by IO access. In each case,
casualty was found to have a secondary gunshot wound just there was no documented clinically significant hypotension,
below the right gluteus. There was no documented exacerba- seizures, or anaphylaxis during the preevacuation period im-
tion of hypotension, seizures, or anaphylaxis following TXA mediately following TXA administration.
administration.
Discussion
Case 6
A US Servicemember sustained a gunshot wound to the ab- The present series examined six cases of flush administration
domen and another to the left upper extremity. On initial as- of 2g TXA into warfighters who sustained traumatic wounds.
sessment by 75th Ranger Regiment medics, he was alert, with This 75th Ranger Regiment protocol is simpler and much

initial vital signs of HR 110, SBP 80, RR 22, and Spo of 98%. faster than the 2019 TCCC TXA protocol, which requires
2
A tourniquet was applied to the left upper extremity and an a drip bag, continuous unobstructed tubing, two levels of
occlusive dressing was applied to his abdominal wound. IV sequential dosing (1g over 10 minutes follow by 1g over 8
access was established and the 2g IV TXA flush was admin- hours), and continuous elevated fluids without backflow for
istered within 20 minutes of casualty assessment, 10 minutes the duration of TXA administration. This simplified protocol
before evacuation. Post-TXA vital signs were not documented. decreases task saturation, reduces cognitive barriers, and pro-
There was no documented seizure or anaphylaxis between vides an executable strategy for tactical medics across a wide
TXA administration and evacuation. range of mission demands.

Times to TXA and Evacuation We found no empirical evidence of increased hypotension,
seizures, or anaphylaxis with this novel approach to TXA
Times to TXA and evacuation are graphically displayed in Fig ure administration. Though far from conclusive, present findings
2. Across the six cases, times from assessment to TXA averaged are encouraging. TXA was administered relatively quickly,
17 minutes (SD 17 minutes, range 2–45 minutes). Times from well within the 3-hour guideline from time of injury. Fur-
14

TXA to evacuation averaged 42 minutes (SD 47 minutes, range ther, while the 2019 TCCC TXA protocol is complicated and

88 | JSOM Volume 20, Edition 4 / Winter 2020