Tranexamic acid (TXA) is an old drug, but one that we in emergency medicine have found love for once again. In preparation for an upcoming talk at a conference, I realized I had not yet made a post regarding TXA. This is a quick summary of TXA and links to a lot of great #FOAMed resources out there you can also check out regarding the same. I have also included one bit that I have recently found very successful but with little evidence currently. Listen to the podcast for more!
Probably the most well-known example of using TXA in emergency medicine is from the CRASH-2 Trial which was an international study using TXA in trauma. The NNT for this treatment is 1 in 67 which is not bad for a low cost intervention without a real NNH. Multiple groups like Core EM, EmCrit, JEMS, emDOCS, The Bottom Line, and the SGEM have all made articles on this discussion. EmCrit even did a second post for the doubters out there on this study. Whether or not you believe the findings, you should listen to that post. The easiest way to consider when to give TXA is if the patient is needing blood. If they need blood, they probably need TXA. Time is of the essence since less than three hours needs to be the goal. Later than that means a potential for an increase in mortality. The easy way to deliver this medication is 1000mg (1 gram) over 10 minutes and then another gram delivered over the next 8 hours to match the study. This is important to know, especially if you work in a rural or remote setting where you have to make these decisions quickly before you transport this patient to definitive care.
The WOMAN Trial has also hit the press recently. There is a lot more controversy regarding this trial and it is something you will need to research more to make your own decision (like any other really). Some of my favorite posts are by REBEL EM, FOAMcast, Broome Docs, The Bottom Line, and EM Lit of Note. If you were to read them all there is evidence that some are strongly for the results and believe TXA should be used while others have their reservations. This will most likely remain controversial but in the end, with massive bleeding, there is a role for TXA.
Topical bleeding control is another area of benefit for TXA. Epistaxis is a great area for TXA to shine more with newer evidence. One RCT from 2013 outlined a specific approach and this was very well covered by the SGEM and emDOCS. Though this trial used it basically in packing, an atomizer could be used but this really has not been study in such a form.
Oral bleeds are another type of bleeding that we sometimes see in emergency medicine. The best post out there is by REBEL EM for this topic. In that same post he also talks about safety of TXA and using this drug in hyphemas. This has also been talked about on ER CAST though and is worth the listen.
My final area of using TXA is with cutaneous bleeds. The are usually the little varicose vein bleeds or the lacerations that are bleeding just enough to be difficult that cannot or should not be controlled by other measures. When direct pressure is not enough or other methods such as Surgicel or silver nitrite stick are contraindicated (or even failed), what comes next? In the small bleed that will just not stop there is nothing to suture and nothing to really compress. Tourniquets may stop bleeding temporarily but do not actually correct the problem. Topical TXA (anecdotally) has been very beneficial in such cases. ER CAST briefly had this mentioned in an episode recently. Academic Life in Emergency Medicine also came up with a paste that could help which could be applied to such bleeds. Other methods of delivery could be by an atomizer or placing on a bandage (or even something like Surgicel). Ultimately, TXA can be your friend and it would be even better with more evidence.
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