RN, BA, MA, MSN
A 19-year-old female presents to the emergency department (ED) with oral hemorrhage after a recent tonsillectomy. One hour into her ED evaluation, she began bleeding, leaving greater than five hundred milliliters (mL) of blood in the emesis basin. She becomes anxious, pale, diaphoretic and tachycardic at 124 beats per minute (bpm) and hypotensive with a blood pressure of 84/54 mm Hg. She requires frequent oral suctioning for airway protection. Secondary to the large volume of hemorrhage and continued bleeding without the potential for rapid operative intervention, she receives one unit of uncrossmatched packed red blood cells (PRBC) and nebulized TXA 1000 mg / 10 mL. Under these circumstances, rapid evaluation of the surgical emergency is required to treat post-tonsillectomy hemorrhage, the most common serious complication of tonsillectomy.
For a subset of drugs, there can be a revival and repurposing as we discover new applications and uses. Having spent any time in an emergency room or around a trauma patient, you may have administered TXA (Tranexamic acid), an indirect or antifibrinolytic inhibitor, released from Shosuke Okamoto’s lab in the 1960s.
Though other medical applications exist, first case applications of TXA involved women with heavy menstrual blood loss and patients with hereditary bleeding disorders. Since discovery, TXA has found a host of new therapeutic uses.
Within human pathophysiology, an antifibrinolytic drug inhibits fibrinolysis by blocking the activation of proenzyme plasminogen. In short, they are a class of drugs that help the blood clot. Current antifibrinolytic agents include Amicar, Aminocaproic acid, Aprotinin, Cyklokapron, Fibrinogen, human, Fibryga, Lysteda, Riastap, Tranexamic acid and Trasylol.
First approved by the FDA in 1986 as a short course injection (2-8 days), TXA intravenous (IV) solution and oral tablets prevented bleeding in hemophilia patients during tooth extraction.
What does TXA do? In four words, TXA reduces blood loss. In trauma, the indications for TXA are in patients with massive bleeding.
Secondary to the initial trauma, associated trauma-induced coagulopathies (TIC) cause significant mortality. Data from the international 2010 CRASH-2 (Clinical Randomization of an Antifibrinolytic in Significant Hemorrhage) involving over 20,000 patients showed survival after TXA administration increased when compared to placebo.
The CRASH-2 trial evaluated TXA effects with early administration in trauma and vascular occlusive events. In contrast to early data from CRASH-1, the CRASH-3 trial found that TXA reduced head injury death in patients with TBI.
To reduce death, TXA administration should occur within 3h of injury.
TXA Trauma Protocol:
Contraindications:
Adverse Effects:
TXA administration requires an infusion pump. The standard loading bolus dose is one gram over 10 minutes (Supplied in vials of 1gram / 10 ml). Standard IV infusion dose is one gram (added to 250cc) over 8 hours. In non-traumatic use cases, TXA administration includes oral, intravenous, topical, nebulized or as mouthwash.
There are applications for TXA in bleeding aside from traumatic injury. TXA has shown to reduce bleeding in patients having cardiac surgery, epistaxis, dental extraction, gynecological surgeries, orthopedic surgeries, liver and kidney surgeries, oral and maxillofacial surgeries, dermatologic procedures and nebulization in post-tonsillectomy hemorrhage. There was no mortality changes in lower gastrointestinal bleeding.
Providers should avoid TXA in urinary tract bleeding, secondary to the potential of intrarenal clot formation. The CRASH-1 trial data showed that after three hours, treatment was likely to be ineffective, but the CRASH-2 study showed that TXA administered to bleeding trauma patients within 8H of injury reduced death secondary to bleeding.
Postpartum hemorrhage is the leading cause of maternal mortality in the world, accounting for over 100,000 deaths every year. Evidence suggests that TXA reduces postpartum bleeding demonstrated in the WOMAN Trial (World Maternal Antifibrinolytic Trial) in which TXA administration reduced maternal bleeding deaths by one third.
TXA reduces mortality in hemorrhaging patients by one-third when given within 3 hours regardless of the baseline risk and injury.
Love what you read?
Share our insider knowledge and tips!
Read More
Specialties Nurse Practitioner: Nursing Specialties Breakdown Becoming a nurse practitioner is a multi-step process, including education, clinical experience, and licensure. There are several specialties and environments that NPs can work in, ranging from family nurse...
Specialties Perioperative Nurse: The Journey Behind the “Authorized Personnel Only” Doors A medical-surgical nurse describes the journey of becoming a perioperative nurse and what truly takes place in the operating room. One must fully understand the requirements of a...
Specialties Dermatology Nurse: Nursing Specialties Breakdown Learn the steps to become a dermatology nurse Acknowledge special skills and traits to become a dermatology nurse Understand the working options, responsibilities, and benefits of a dermatology nurse ...