Tranexamic Acid in Trauma (Adults and Children)

• Summary of Guideline
• Aims
• Background
• Diagnosis
• Investigation
• Treatment / Management

Summary of Guideline

Tranexamic acid has been found to improve outcome in adult patients with bleeding as a result of trauma if administered within 3 hours of injury. Expert opinion is that this finding in adults can be extrapolated to children.

All patients (adult and paediatric) without contra-indications who are bleeding or who are at risk of significant bleeding as a result of trauma should be given tranexamic acid if the initial bolus dose can be given within 3 hours of injury.

Tranexamic acid should also be given to adults with traumatic intracranial haemorrhage within 3 hours of injury if they have not already received it. Use in children with traumatic intracranial haemorrhage should be considered on a case by case basis.

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Aims

To increase usage of tranexamic acid in the care of trauma patients

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Background

The CRASH-2 study has identified that tranexamic acid is a cheap and effective pharmacological intervention in patients who may be bleeding as a result of trauma. The Royal College of Paediatrics and Child Health has established guidance on the use of tranexamic acid in paediatric trauma patients. The CRASH-3 study has identified that tranexamic acid can reduce head injury associated deaths.

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Diagnosis

All patients who have suffered trauma and who the senior clinician caring for them feels may be bleeding or at risk of significant bleeding (and importantly not just those requiring massive transfusion).
All patients with a traumatic head injury AND GCS 12 or less and injury less than 3 hours.
All patients with a traumatic head injury, GCS 13-15 and TBI on CT and injury less than 3 hours.

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Investigation

No investigations are required prior to the commencement of tranexamic acid. If no significant bleeding is identified following investigation the tranexamic acid can be discontinued.

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Treatment / Management

Note: The initial bolus dose may have been given pre-hospital - check with the pre-hospital team.

Adults: 1gram intravenously over 10 minutes within 3 hours of the onset of haemorrhage / TBI followed by a further 1gram intravenous infusion in 100ml sodium chloride 0.9% or glucose 5% over 8 hours. The infusion should be stopped if investigations show that no significant bleeding has occurred and if no traumatic brain injury is demonstrated on CT.

Paediatrics: Loading Dose – 15mg/kg (max 1g) diluted in a convenient volume of Sodium Chloride 0.9% or Glucose 5% and given over 10 minutes
Maintenance infusion – 2mg/kg/hour. Suggested dilution 500mg in 500ml of sodium chloride 0.9% or glucose 5% given at a rate of 2mls/kg/hour. For up to 8 hours. The infusion should be stopped if investigations show that no significant bleeding has occurred. MAXIMUM infusion dose of 1g.

TBI & Paediatric patients: tranexamic acid should be considered for paediatric patients with TBI. The CRASH-3  trial did not include patients aged <16 years and therefore cannot provide any evidence of a treatment benefit in children. The findings of the CRASH-2 trial in adult patients were adapted for clinical practice in children by the Royal College of Paediatrics and Child Health using a pragmatic dosage schedule of 15mg/kg loading dose (max 1g) followed by maintenance infusion of 2mg/kg/hour (max 1g) for a maximum of eight hours…. It is for individual clinicians to decide on their approach for children.

Contraindications:
Relative (assess risk vs benefit on an individual patient basis). In many cases it will not be possible to obtain a full history. If there is a realistic suspicion of significant bleeding the benefits will most likely outweigh the risks.

• Patients with previous deep vein thrombosis (DVT), pulmonary embolism (PE) or arterial thrombosis
• History of convulsions
• Patients with indwelling cardiac stent
• Severe renal impairment (eGFR less than 29ml/min/1.73m²) due to risk of accumulation. Toxicity in acute overdose is unlikely at doses of less than 140mg/kg (see National Poisons Information Service Toxbase [accessed 12th June 2013]. Even a thin adult of 50kg would only be receiving 40mg/kg if given the full 2g dosage. As the dose is not repeated the risk of accumulation even in severe renal impairment is very slight.

Absolute

• Hypersensitivity to tranexamic acid or any of the ingredients
• Greater than 3 hours between time of injury and initial bolus dose

Tranexamic acid is associated with an increased risk of thrombosis. However in the CRASH 2 study the treatment group had a lower incidence of thrombotic events. The risks are felt to be very small.