Hello to all, I recently got into a heated discussion about TXA with another service and was wanting to see what services are using it and how they administer the drug to a trauma patient. My service has two routes . We mix 1 gram in a 100 ml bag of NS on a 60 drop set wide open, this will infuse the med in around 9 minutes and change. We also can iv push at 100 mg /min over 10 minutes. Now my question is this. This other service rapid IV pushes the TXA like Adenosine . Now I already know the answer to this but wanted to get some insight from other professionals . Rapid push causes hypotension from what I have read which of course we are trying to avoid. I have searched the internet to see if anybody is doing this and all i can find is a trial being done on pigs in Australia . Anyway lets have a discussion
TXA
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NPO
Forum Deputy Chief
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Standard accepted practice is 1gram over 10 minutes followed by 1 gram over 8 hours. There have been studies to evaluate other options but this has been the most fruitful.
dutemplar
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We drop two amps (total 1 gram) in a 100 NSS and 5-10 minutes. Generally it's set to a quick drip and just ran in the ballpark.
E tank
Caution: Paralyzing Agent
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Why did it get heated? They didn't approve the protocol, their medical director did. Just ask for the documentation/ rationale and supporting literature for it. I'm curious myself.
VFlutter
Flight Nurse
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Our protocol for TXA loading dose is 1g in 100 ml over 10 mins however in reality most slow IVP it over a few minutes. The over 10 mins is due to concern with transient hypotension possibly associated with rapid pushes in the CRASH trial however these patients were shocky and hypotension was likely multi-factorial. Current understanding is that rapid push is unlikely, if at all, to directly cause hypotension. I believe Rangers and some in military are giving 2g bolus up front now with no drip at all.
Slow IVP is likely appropriate and safe but I see zero reason to "slam" it like Adenosine.
Slow IVP is likely appropriate and safe but I see zero reason to "slam" it like Adenosine.
hometownmedic5
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1gm 100ml 10min(ish). I see no benefit to slow IVP. I likely as not need my hands for other things.
FiremanMike
Just a dude
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Thanks for that, I couldn't remember the rationale for 10mins but forgot to research why..
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Same as most, 1G over 10 minutes (I use the pump), followed by 1G over eight hours which the hospitals appear to care less about and just throw away it seems. Perhaps some promise to 2-3G single bolus (slow) I heard on the last EMUpdate.
We do 1g over 10 minutes. We have ours prepackaged by vehicle supply technicians to come with macro 10 gtt drip sets instead and were trained to do it similar to our Amiodarone drips, 100 gtt/min. We started this protocol 8 months ago and it has only been used twice I think. One of the times was done inappropriately/didn't meet protocol to give. I've done an Amiodarone drip only once, but never a TXA drip. We don't have a bolus dose. The majority of our transports are probably <5 miles so not usually enough time to give it and very few major traumas that meet the requirement anyways.
Bishop2047
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Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial - PubMed
UK National Institute for Health Research Health Technology Assessment Programme.
pubmed.ncbi.nlm.nih.gov
Just about every study involving TXA seems to sing its praises, and list of uses for TXA ever growing.
This study however concerning GI bleeds. The findings showed.... Negative outcome with the use of TXA. Really neat and well put together project.
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It feels like every TXA study sounds great and then you look at it and it's "death by X cause was reduced." Not real helpful when you're still dead.Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial - PubMed
UK National Institute for Health Research Health Technology Assessment Programme.
Just about every study involving TXA seems to sing its praises, and list of uses for TXA ever growing.
This study however concerning GI bleeds. The findings showed.... Negative outcome with the use of TXA. Really neat and well put together project.
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pregnancywhine
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It is usually a quick drip and just ran in the ballpark.
NPO
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This is my protocol and experience with it as well.
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This is the case more often than not with new “cutting edge” drugs and techniques.
I made this observation (on this forum, I think) a year or two ago about TXA and got lambasted for being a a non-believer.
CALEMT
The Other Guy/ Paramaybe?
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I mean God forbid you have a different opinion or view of something in the medical field.
For the sake of being on topic like everyone else we do 1 gram in a 100ml bag over 10 minutes... shocking...
Same thing happens every time I’ve brought up the risk of PE and stroke.
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To my knowledge the recently published HALT-IT trial regarding TXA use in GI bleeding was the first to demonstrate a statistically significant increase in thromboembolic events.
Bishop2047
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You are correct, to my knowledge.
In short the Idea seems to be...
Major multisystem trauma ='s Benefits outweigh negative side effects.
Isolated system insult ='s Negative side effects outweigh benefits.
It may be of use in postpartum care, though margins are slim.
TXA in Post-Partum Hemorrhage
This post is cross-posted on REBEL EM. Post-partum hemorrhage (PPH) is the leading cause of maternal death worldwide. It is typically defined as > 500 ml of blood loss within 24 hours of giving birth. However, PPH encompasses a broad spectrum of disease from mild oozing over hours to rapid...
coreem.net
There are several studies and case reports of thrombotic events. I think it important to keep in mind that a lot of the early data on TXA was coming out of the military which has a relatively young and healthy population compared to civilians.
Tranexamic acid and thrombosis. Prescrire Int. 2013 Jul;22(140):182-3. PMID: 23951593.
Myers SP, Kutcher ME, Rosengart MR, Sperry JL, Peitzman AB, Brown JB, Neal MD. Tranexamic acid administration is associated with an increased risk of posttraumatic venous thromboembolism. J Trauma Acute Care Surg. 2019 Jan;86(1):20-27. doi: 10.1097/TA.0000000000002061. PMID: 30239375.
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Tranexamic acid and thrombosis. Prescrire Int. 2013 Jul;22(140):182-3. PMID: 23951593.
Myers SP, Kutcher ME, Rosengart MR, Sperry JL, Peitzman AB, Brown JB, Neal MD. Tranexamic acid administration is associated with an increased risk of posttraumatic venous thromboembolism. J Trauma Acute Care Surg. 2019 Jan;86(1):20-27. doi: 10.1097/TA.0000000000002061. PMID: 30239375.
Download .nbibFormat:
Yep! Most patients with significant GI bleeds are much sicker at baseline than a young trauma patient. 41% of these patients had liver disease, 45% concern for varices in HALT-IT.