Tranexamic Acid in Major Bleeding

Rationale:

Part of the response to surgery and trauma is stimulation of clot breakdown (fibrinolysis), which may become pathological.

Antifibrinolytic agents reduce blood loss in patients with both normal and exaggerated fibrinolysis, without increasing risk of post-operative vascular occlusive complications. The CRASH-2 study revealed a 15% reduction in overall mortality.

Lysine analogues (tranexamic acid - Cyclokapron^®) work by inhibiting the conversion of plasminogen to plasmin, and preventing the binding of plasmin to fibrin.

Evidence:

CRASH-2 trial collaborators. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 2010;376(9734):23 – 32.

Napolitano LM, Cohen MJ, Cotton BA, Schreiber MA, Moore EE. Tranexamic acid in trauma: How should we use it? J Trauma Acute Care Surg. 2013;76(6):1575-1586.

Protocol:

• In adult trauma patients with severe haemorrhagic shock (SBP ≤ 75 mm Hg), with known predictors of fibrinolysis (severe trauma, massive transfusion, inflammation, metabolic syndrome);
• Only administer TXA if less than 3 hours from time of injury;

[If you have access to immediate thromboelastograms, show that fibrinolysis is LY30 > 3%; but do not delay administration of TEG is not available.]

Administer 1g of tranexamic acid (Cyclokapron) IV over 10 minutes.

[Cyclokapron is packaged as 500mg/5ml ampoule.  Therefore, administer 2 ampoules in 200ml saline over 10 minutes.]

Follow with 1g tranexamic acid IV over 8 hrs (in 200ml or 1000ml saline).

There are no contra-indications to the administration of tranexamic acid under the above circumstances.