TXA a bleeding wonder drug!

Crash 2 Study (2010)

• Multi-Centre RCT of the use of TXA in trauma
• Inclusion – Adult trauma patients with ≥1 of
  • Suspicion of significant haemorrhage
  • HR ≥110bpm
  • sBP ≤90mmHg
• Treatment – 1g TXA IV over 10min then a second 1g TXA IV over 8hrs
• Outcome – Significant reduction in Death, bleeding with NO increase in clots(thrombotic disease)
  • Most benefit seen if given early (<3hr – NNT 53)

Crash 3 Study (2019)

• Multi-Centre RCT of the use of TXA in traumatic brain injury
• Inclusion – Adult trauma patients within 3hrs of injury with ≥1 of
  • GCS ≤12
  • Intracranial bleed on imaging
  • No other significant bleed (as they would likely get any way post Crash 2)
• Treatment – 1g TXA IV over 10min then a second 1g TXA IV over 8hrs
• Outcome – Significant reduction in Death with NO increase in clots(thrombotic disease)
  • On metanalysis within paper benefit shown for all patients
  • Results of this paper showed the largest benefit is in:
    • Mild-Mod Head injury (GCS9-15)
    • Patients with reactive pupils

Mechanism of action

This video explains it brilliantly  and shows why early administration is so important!

Author comments (Dr Ian Roberts @ RCEMasc 2019)

• Inhibits fibrinolysis – i.e. stops plasmin breaking down clots
• Treats bleeding – NOT coagulopathy
• Given TXA Early – as tPA activates early and PIA-1 is later, we need to stop the tPA
  • 15min treatment delay > 10% reduction in effect
• Give on the suspicion of bleeding? – you get the same risk reduction  what ever your base line risk (i.e. 30% risk of death > 20%, 3% risk > 2%)
• Safety – in Japan TXA bought over the counter for headaches
• RCT’s
  • Surgery – TXA reduces blood loss by 1/3 & death, NO increase in clot events
  • Post-Partum Haemorrhage – PPH reduced by 1/3
  • Trauma – Sig. reduction in DEATH (<1hr reduced by 1/3, 1-3hr by 1/5)
  • Vascular occlusive events – data seems to show TXA reduces them
    • Bad bleeding  increases vascular-occlusive events
  • Brain  – Given with in 3hrs reduces deaths
  • GIT – results due next yea, recruitment stopped in uk as TXA was being give anyway
• Why have the infusion? – added to regime to (theoretically) replace the loses from ongoing bleed, its utility is unknown.