Rev Col Bras Cir. 2012;39(1):77-80.
Tranexamic acid for traumatic hemorrhage.
[Article in English, Portuguese]
Luz LD, Sankarankutty A, Passos E, Rizoli S, Fraga GP, Nascimento Jr B.
Besides being directly responsible for most of the early in-hospital deaths, bleeding can also contribute to late mortality related to multiorgan failure in trauma1. Bleeding trauma patients may develop a complex and unique coagulopathy; where multiple mechanistic factors such as dilution, consumption, acidosis, hypothermia, poor fibrinogen utilization, and excessive clot breakdown (hyperfibrinolysis) are responsible for its development2.
Clot breakdown (fibrinolysis) is a normal response to surgery and trauma in order to maintain vascular patency and can become exaggerated (hyperfibrinolysis) in some cases. The antifibrinolytic drug tranexamic acid (TXA), a lysine analogue, interferes with the binding of plasminogen to fibrin, which is necessary for plasmin activation. Fibrinolysis consists of activated plamin cleaving fibrin. Antifribrinolytic drugs can prevent clot breakdown and thus reduce blood loss in surgery3. In elective surgery, TXA reduces blood transfusion by a third, without significant reduction in mortality or increased postoperative complications3. TXA has recently been shown to reduce deaths in a large population of trauma patients4.
The TBE-CiTE Journal Club performed a critical appraisal of the most important evidence recently published on the topic and provides evidence-based recommendations on the use of TXA in trauma.
The conclusions reached by at the telemedicine meeting are based on 3 recent publication and a systematic review:
· The CRASH-2 study, a large placebo-controlled randomized clinical trial that included over 20.000 trauma patients;
· Its subgroup analysis; and
· The MATTERs trial, a fairly large retrospective study in combat injury including 896 patients;
· A Cochrane systematic review of the literature published in 2011, on the use of anti fibrinolytic for the treatement of traumatized patients that are bleeding9.
These 4 publications together studied over 30.000 patients and they suggest that TXA reduces mortality in civilian and military trauma patients without increasing the risk of complications. The two studies of the CRAS-2 suggest the drug should be administered in low-doses and routinely in the management of bleeding trauma patients, but only in the first 3 hours after the trauma.
TBE-CiTE Recommendation on the use of tranexamic acid for the management of traumatic bleeding
1. Tranexamic acid should be routinely used in trauma patients with evidence of bleeding;
2. Tranexamic acid should be included in transfusion protocols for trauma;
3. Tranexamic acid should be given within 3 hours of injury;
4. Administer 1g of TXA intravenously (bolus over 10 minutes) followed by the infusion of 1g over 8 hours.
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