# Blood coagulant during internal bleeding



## BrushBunny91 (Nov 4, 2011)

Can medic's do or push anything to help with internal bleeding? Such as a coagulant.


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## JPINFV (Nov 4, 2011)

Like fresh frozen plasma? No.


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## Handsome Robb (Nov 4, 2011)

Nope. Well NS/LR for volume replacement thats about it  haha but how are you going to control where the blood coagulates and where it doesn't?

Surgery is the definitive intervention to control internal bleeding.


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## BrushBunny91 (Nov 4, 2011)

With any med I'd hope it sticks 
How about a blood thickener? I'd assume it would put undue stress on the heart but could it help?


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## Handsome Robb (Nov 4, 2011)

Not that I'm aware of. Like you said your adding stress to a heart that already is working hard.

There's a whole clotting cascade that has to happen.


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## JPINFV (Nov 4, 2011)

...again, paramedics aren't going to carry fresh frozen plasma around.


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## BrushBunny91 (Nov 4, 2011)

JPINFV said:


> ...again, paramedics aren't going to carry fresh frozen plasma around.



My apologies, I didn't know if there was something out there that could substitute plasma or not.


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## JPINFV (Nov 4, 2011)

The thing about FFP is that it contains the coagulation factors (albeit not the platelets, but platelets already have an insanely short half life). The problem with other IV solutions is how do you get the clotting to occur only at the site of the injury, instead of systemically, while also bypassing the clotting cascade?


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## BrushBunny91 (Nov 4, 2011)

I've got a number of lucrative ideas on how, and half involve nanorobots, but I have no intelligent idea on how to direct the clotting factors.


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## DV_EMT (Nov 4, 2011)

qwik-clot.... but thats usually internal/external bleeding.

What about albumin?


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## JPINFV (Nov 4, 2011)

Albumin isn't involved with clotting. It's involved with maintaining oncotic pressure and as a carrier protein.


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## DV_EMT (Nov 4, 2011)

JPINFV said:


> Albumin isn't involved with clotting. It's involved with maintaining oncotic pressure and as a carrier protein.



I knew you'd have a good answer for that. ^_^


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## systemet (Nov 4, 2011)

BrushBunny91 said:


> I've got a number of lucrative ideas on how, and *half involve nanorobot*s, but I have no intelligent idea on how to direct the clotting factors.



Awesome!

There's the option in the hospital to try and reverse anticoagulants, e.g. protamine for heparain, or vitamin K for warfarin / coumadin.  I'm not sure how often this is done.  I don't know if it affects the risk for DIC.

These medications aren't typically carried in EMS, probably due to the low incidence of life-threatening internal bleeding, and the lack of point-of-care testing to see if the patient's anticoagulants are even therapeutic.


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## mycrofft (Nov 4, 2011)

*Well, try these:*

1. Minimize movement so any clotting will take hold and not be shifted around, then go to step 2 ASAP.
2. Apply tincture of throttle and beat feet to definitive care.

What sort of "internal bleeding" are you thinking about? Subperiostial hematoma, intracranial bleed, ruptured spleen, punctured liver, ruptured esophageal varix?

Hypothetically speaking, anything that would clot a major bleeder fast enough to save the life on scene would probably clot everything else solid. Plus, on scene you will probably not know if there is the dreaded "internal bleeding", you will see someone with signs of shock, maybe be able to get allergies-meds-and some history before the pt is out of it and you have them in your ambulance.


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## boingo (Nov 4, 2011)

Tranexamic acid, although not a clotting agent per se, may see a role in the EMS environment sometime in the near future.


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## Tigger (Nov 4, 2011)

DV_EMT said:


> qwik-clot.... but thats usually internal/external bleeding.
> 
> What about albumin?



How is quick-clot useful for internal bleeding?


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## DV_EMT (Nov 4, 2011)

Tigger said:


> How is quick-clot useful for internal bleeding?



I was refering to an open arterial bleed...


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## mycrofft (Nov 4, 2011)

*My old professor drove ambulances during The Blitz.*

They would kneel with one knee firmly in the gut to hopefully narrow the descending aorta to "buy time" for horrific lower extremity wounds. Didn't work much.


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## KellyBracket (Nov 4, 2011)

Like Boingo said, aminocaproic acid may be used in the future, especially with this massive trial done recently:

http://www.ncbi.nlm.nih.gov/pubmed/21249666


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## BrushBunny91 (Nov 5, 2011)

Two trials with a combined total of 20,451 patients assessed the effects of TXA on mortality; TXA reduced the risk of death by 10% (RR=0.90, 95% CI 0.85 to 0.97; p=0.0035).:censoredata from one trial involving 20,211 patients found that TXA reduced the risk of death due to bleeding by 15% 

Some pretty interesting stuff!


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## mycrofft (Nov 5, 2011)

*Interesting study*

The questions I would have for the authors would be if this was a study regarding open trauma clotting cases (incisions and the l,ike), and does "no evidence" of vascular occlusive problems mean it was studied and found lacking, or, since the focus was on trauma, if such instances were not considered. (Like when they, the folks who make Roux-en-Y hardware, studied Roux-en-Y gastric bypass and declared it safe by cutting off the post-surgical survival frame at eighteen months, when an expanded impartial study found that after eighteen months mortality continued and nearly doubled by three years' out).
EDIT: http://en.wikipedia.org/wiki/Tranexamic_acid
I feel stupid, I did not even think about maternal hemorrhage post-delivery, a very serious bleeding episode and which has been addressed with TXA and fundal massage; no study cited, but that is a big area of internal bleeding we in urban Western countries don't think about. It is OTC in Sweden and becoming so elsewhere, for menstrual bleeding, although it has been shown to cause thrombosis and necrosis of uterine fibroids.


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## rexbanner (Dec 22, 2011)

Our province (Alberta) is seriously considering placing Tranexamic acid on car. While the new drug would take awhile to train and place on trucks provincally, it could definately be a life saver for some of these rural and remote incidents. Wonder how much it actually extends that golden hour...


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## Commonsavage (Dec 23, 2011)

boingo said:


> Tranexamic acid, although not a clotting agent per se, may see a role in the EMS environment sometime in the near future.



Which is what we use, here in my clinic, in Iraq, for GI bleeds.


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## triemal04 (Dec 23, 2011)

One of the clotting factors may eventually become a standard treatement option, though probably not in the field.  There was a study that looked at either factor IV or VII (I blame a day of drinking for my memory lapse) as a treatement for acute intracerebral hemmorhage that had promising results until it was fully analyzed; last I heard it was being redone with a more selective entry criteria.

Of course, that was for a specific, localized injury, not massive or potentially massive bleeding.


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## rexbanner (Dec 26, 2012)

So this protocol went live about 6 months ago. Acute hemorrhage control protocol. Includes Tourniquets, pelvic binding, and TXA. 

I had the opportunity to give TXA last week and I would have to say it saved the patient’s life. Severe high speed MVC T-Bone to passenger side. Pt had prolonged extrication 20-30 minutes. Flat belly when initially removed progressing to extremely distended and firm abdomen. Pressure started to tank (below 60-70) and HR climbed. Classic hemorrhagic shock. Our protocol is to patch to OLMC for approval for administration of 1g of TXA IV over 10 minutes. 

Patient was flown a short distance to a Trauma center. 

I followed up a few days later expecting him to have succumbed to his injuries but it turns out he is alive. Torn abdominal aorta, torn iliac artery, fx femur, fx radial ulna. Abdominal and iliac arteries both clotted on their own. They didn't have to go in surgically to the aorta when he arrived. They were considering going in post stabilization to repair the tear but decided not to.

In my "non MD" opinion, this man was saved by the TXA.

TXA inhibits the activation of plasgminogen to plasmin.


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## Merck (Dec 26, 2012)

We've been using TXA in BC at our Critical Care Paramedic level for scene responses and IFTs within the window for almost two years.  Great anecdotal success.


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## alabamatriathlete (Dec 28, 2012)

My big question is - even if you know, or suspect, there is bleeding internally, how do you know where the bleed is? 

Civi-side, get them to ER/OR. Mil/tac-side, we're probably just going to chest-tube and attempt to stabilize until further care can be provided.


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## jwk (Dec 28, 2012)

Aminocaproic acid has been used for years in cardiac surgery - it's not really a new drug, but the indications are expanding.  It is an anti-fibrinolytic drug, essentially a "clot stabilizer" - it keeps clots from breaking down.

There is a synthetic Factor VIIa called NovoSeven.  We use it on rare occasions for intractable hemorrage (along with FFP, platelets, and cryoprecipitate) usually caused by DIC.  In my particular facility, due to our huge OB volume, we have a fair number of OB hemorrhage cases.  This is one of the drugs of last resort.  I doubt it finds it's way into pre-hospital use anytime soon, because the wholesale cost is on the order of $7,000 per dose.


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## RustyShackleford (Jan 8, 2013)

As has been stated already we now use txa in Alberta, I haven't seen it used in the field so in regards to its efficacy I suppose time will tell.


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## mycrofft (Jan 8, 2013)

rexbanner said:


> So this protocol went live about 6 months ago. Acute hemorrhage control protocol. Includes Tourniquets, pelvic binding, and TXA.
> 
> I had the opportunity to give TXA last week and I would have to say it saved the patient’s life. Severe high speed MVC T-Bone to passenger side. Pt had prolonged extrication 20-30 minutes. Flat belly when initially removed progressing to extremely distended and firm abdomen. Pressure started to tank (below 60-70) and HR climbed. Classic hemorrhagic shock. Our protocol is to patch to OLMC for approval for administration of 1g of TXA IV over 10 minutes.
> 
> ...



Holy excremento. Yeah, the aorta will need something (an encasing stent or some such), but to monkey with it when it's apparently holding for now would be an operative misadventure.

Watch, someone will start messing up its use and it will get thumbed out for a while because it's gone from "mother's  milk" to "dangerous".


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## Veneficus (Jan 8, 2013)

rexbanner said:


> In my "non MD" opinion, this man was saved by the TXA.



Knowing what I do, I disagree with your opinion.

I respectfully suggest you look up the mechanisms and treatment strategies of tears in large caliber arteries. 

TXA may have helped, but certainly wasn't the deciding factor.

There is just too much in play for magic bullet remedies like this.


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## mycrofft (Jan 8, 2013)

Veneficus said:


> I respectfully suggest you look up the mechanisms and treatment strategies of tears in large caliber arteries



Got it, thanks or the PM as well.


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## AUSEMT (Jan 9, 2013)

Paramedics in Israel can carry FFP, artificial plasma products and tranexamic acid

some flight paramedics in Australia (esp. Melbourne) can carry FFP & RBC's / O- neg transfusions/


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## CANDawg (Jan 9, 2013)

FFP & other blood products are in the medic scope here, but they are much too precious to be carried on ambulances. Usually only seen on transfers, or administered by clinic paramedics. (The local helicopter EMS service might carry them though, not sure on that one.) TXA is on the books for possible inclusion on ambulances though, not sure of the status.

EDIT: Just saw someone else mentioned the same thing earlier. That's what I get for not reading the whole thread! :haha:


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