The use of Transexamic (spell that 10 times fast) Acid, or TXA, in trauma is largely based on the CRASH2 trial. This was a large, multi-center, randomized controlled trial with over 20,000 patients that demonstrated a mortality benefit of TXA for trauma patients when initiated within 3 hours of the injury. The NNT is 68, with an absolute risk reduction of 1.5%. None of the secondary outcomes of the study showed any benefit (including need for transfusion, amount of products transfused, need for surgical intervention, or thromboembolic events).  There was added benefit for patients in significant shock with systolic blood pressures less than 75mmHg.

In short, TXA works by inhibiting fibrinolysis. It has other uses outside the trauma room, which we won’t discuss here.

The trial used a loading dose of 1gram over 10 minutes, followed by a second dose of 1g infused over the next 8 hours. I have often ordered the first gram, but have had patients who were in our department for some more time (rather than immediately making it to the SICU or OR) for whom I have not ordered the second dose. As we all know, the momentum of ED orders and procedures carrying forward (see those vent settings for an example, or your copy/pasted initial HPI in every note up to the discharge summary) is influential in the patient’s care. Consider placing the order for the second dose. Food for thought.

June 2024