TXA Implementation Pages - How to do it
I have written these web pages to talk about the best ways to implement Tranexamic Acid (TXA) into your clinical practice in Emergency Medicine.
What is the evidence for the use of TXA?
The CRASH2 trial studied the use of tranexamic acid in the management of injured patients. The results of the trial were published in the Lancet in 2010, with a follow up paper in the Lancet in May 2011. The trial showed that treatment with tranexamic acid reduced patient mortality from 16% to 14.5%, thus preventing 9% of all trauma deaths. The number needed to treat was 67 – in other words one life was saved for every 67 patients treated. This means that the treatment cost of saving a life is about £200. The potential number of lives that we could save in the UK is about 500 per year. The MATTERS study in 2012 showed a similar survival benefit in military casualties, and an Analysis by Risk of Death published in the BMJ in 2012 showed that the treatment should be given all trauma patients with significant bleeding, not just those with the highest risk of death.
For more discussion there is a podcast on the EMCrit website about the CRASH2 trial results.
This video explains the main results of the CRASH2 trial:
What is the indication for TXA use?
From the trial the indication for use is in trauma patients who you think are bleeding or at risk of significant bleeding (this excludes isolated head injuries). The clinical judgment about whether or not a patient is bleeding or at risk of bleeding is one that you are already making about every trauma patient, and involves weighing up factors such as the mechanism of injury, injuries found, the patient’s physiology, response to treatment and results of investigations. As a rule of thumb, any trauma patient who you group & save or cross match should be given tranexamic acid.
How is tranexamic acid given?
The dose is 1 gram over 10 minutes, followed by an infusion of 1 gram over 8 hours.
TXA is packaged as vials of a clear liquid - the common UK formulation is 100mg/ml so normally 10mls (2 vials) is given for each dose
The ten minute bolus dose is given by injecting 1 gram of tranexamic acid into a 100ml bag of saline and letting it run through over about 10-20 minutes (the exact timing is not crucial). From April 2012 this dose may be given by the ambulance paramedics, but this will take a while to roll out.
The 8 hour infusion is given by injecting one gram of tranexamic acid into a 500ml bag of normal saline and giving it via an infusion pump. If there is a gap between the initial bolus and the subsequent infusion this probably does not matter too much, but ideally one should follow the other.
How soon should it be given?
In the CRASH2 trial there was a strong indication that the earlier tranexamic acid is given the stronger the effect – so getting the initial 10 minute bolus into the patient early is important. My own practice now is to ask for the bolus dose to be prepared as soon as we receive the pre-alert from the ambulance service that they are bringing in a badly injured patient. Tranexamic acid can then be given early if needed, there is then one less thing to do during the resuscitation – and if the tranexamic acid is not needed we are only throwing away a couple of quids worth of drug. There is an indication that TXA should not be given after 3 hours, as the subgroup of patients who died from bleeding did worse if treated late.
How is the implementation of the CRASH2 results going?
The CRASH2 results are now being implemented. The UK military changed their protocols to include tranexamic acid soon after the results were published, so every injured British soldier now receives this drug. The American military have changed their protocols to include tranexamic acid. The 2012 JRCALC guidelines will include prehospital tranexamic acid for all patients triaged to a trauma centre and the European Trauma Bleeding Guideline will also soon be changed to include early treatment with tranexamic acid. However, in civilian practice in the UK implementation has been slower, with less than 1% of patients in the TARN database receiving tranexamic acid last year (2011).
Are there any mistakes being made in implementation?
Some clinicians are making the error of including tranexamic acid in their "Massive Transfusion Protocol”. This was NOT what was tested in the CRASH2 trial, so the effectiveness is not known. There is evidence from the trial data that only half of the lives saved were in this “massive transfusion” group. What the trial tested was the use of tranexamic acid early in trauma resuscitation for ALL patients who were thought to be bleeding or at risk of bleeding – a much wider indication than just those on the massive transfusion protocol.
Some clinicians are performing thromboelastography and only giving TXA to those patients who had "hyperfibrinolysis". Again, this is not what was tested in the CRASH2 trial, so the effectiveness of this strategy is not known. It is likely that TXA is also of benefit in patients who do not have "hyperfibrinolysis" on TEG, so restricting the treatment will mean that a large number of patients will miss out on the benefits.
How can I implement Tranexamic Acid in my Emergency Department?
There are three stages to implementing tranexamic acid in your Department. (1) You need the drug to be stocked in ED, (2) you need the staff to be trained and confident in using the drug, and finally (3) usage should be audited.
(1) How do I ensure that Tranexamic Acid is available?
The first step is to see if you already stock tranexamic acid in your Emergency Department. If not you need to talk to your pharmacist and ask them to help. Your pharmacist will probably prepare an evaluation document which (depending on your local hospital procedures) may have to go to the Trust Medicines Committee. The WHO Essential Medicines Committee evaluation might be a useful resource for your pharmacist.
(2) How do I train my staff?
As tranexamic acid is a very easy treatment to give there is little training required. The main emphasis should be on ensuring that the Team Leaders think about giving treatment early – which can be difficult amongst the hurly-burly of a trauma resuscitation. The ED nursing staff will need to be familiar with the treatment protocol and trained how to draw up and administer the treatment. You will also need to talk to the anaesthetic and intensive care teams, as they will be looking after the patient during the 8 hour infusion.
(3) How do I audit tranexamic acid usage?
The usage of tranexamic acid in the UK is being monitored through the TARN system. As part of the TARN update training your TARN administrator will have been asked to look for the record of tranexamic acid prescription in the patient’s notes and include this data in your Trust’s TARN return.
How important is the implementation of CRASH2?
I think that we are now in an important phase of this research. The CRASH2 trial has given first class evidence about the effectiveness of tranexamic acid. The challenge now for all of us is to ensure that every severely injured patient receives this treatment – which in the UK has the potential to save 600 lives a year. Thank you for reading this. If you want more information please email me at the University of Leicester on firstname.lastname@example.org.
What are people saying about Tranexamic Acid use in trauma patients?
An interview with Jerrold H Levy, the author of the Lancet Editorial on TXA in Trauma. Levy is Professor of Anesthesiology at Emory University School of Medicine and co-director of cardiothoracic anesthesiology:
Comments on the CRASH2 trial results and an analysis of the implications for trauma care practice from the CRASH2 collaborators:
The UK military has been using TXA for every injured soldier since 2010. This video shows how it fits into the military casualty treatment and evacuation protocols:
PS. To end I thought that I would share this with you (I am NOT singing):