TXA Beyond Trauma

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Tranexamic acid (TXA) is a synthetic lysine derivative that binds with the lysine site on plasminogen, inhibits fibrinolysis and stabilizes clot. While it has been around since the 1960’s, its popularity for major trauma has gained a lot of steam in recent years. This has also resulted in creative emergency providers finding novel uses for it at the bedside. In this podcast, Dr. Tim Fallon discusses some of the more novel bedside uses of TXA including epistaxis, hemoptysis, post tonsillectomy bleeding, and dental trauma.

MECHANISM AND FORMULATIONS

  • Tranexamic acid inhibits plasminogen activation to plasmin

  • Less plasmin means less fibrin/clot degradation (and more blood clot stabilization)

  • There are two common formulations available to apply at the bedside:

    • 100 mg/ml IV solution

    • 650 mg tablets

      •     These need to be crushed and mixed sterile water

TXA solution.jpg



EPISTAXIS

epistaxisonlinefirst0714_616441.jpg

  • Place 500 mg (5 ml) TXA on gauze or merocele  

  • Pack for 10-20 minutes

  • Has been shown to improves time to resolution and re-bleeding at 24 hours compared to lidocaine with epi and anterior packing [1]

  • May decrease the need to discharge patient with nasal packing





HOW TO PLACE AN EPISTAXIS TXA PACK BY EMRAP HD

 

HEMOPTYSIS

blood on tissue.jpg

  • 500 mg TXA via nebulizer

  • Wand et al performed a prospective, double-blind, placebo-controlled trial comparing the effectiveness of nebulized TXA (500mg/5ml TID) vs placebo (5 ml of 0.9% normal saline) for 47 patients with non-massive hemoptysis [2]

  • They found a decreased need for surgical intervention and improved bleeding cessation at five days

  • The following were excluded from the trial (limiting clinical applicability of TXA):

    • Massive Bleeding

    • Hemodynamically unstable

    • Pregnant

    • Respiratory instability

    • Renal failure/hepatic failure

    • Coagulopathy (INR > 2)

    • Prior TXA Treatment

  • Check out Rebel EM’s review on this topic


 POST TONSILLECTOMY BLEEDING

Partial-Tonsillectomy.png

  • Schwarz published a case report of a 3 year old with post tonsillectomy bleed [3]

  • While waiting for ENT consultation, 250 mg TXA nebulizer was given

  • Bleeding was stopped



DENTAL

  • TXA paste can be used for bleeding from trauma or post extraction bleeding

  • Crush two 650 mg tablets with a morter and pestle and mix with small aliquots (~0.5 mL) of sterile water until a thick paste is formed

  • Apply paste to bleeding site for 20 minutes

  • There are currently no clinical studies in the emergency department setting

  • Check out ALIEM’s trick of the trade: topical tranexamic acid paste for hemostasis

 
txa dental paste.jpg
 

Tired of reading? Prefer to absorb your MedEd through your wonderful powers of hearing? Listen to the podcast below.


Original Content Authored by Tim Fallon, MD

Edited, Peer Reviewed and Posted by Jeffrey A. Holmes, MD and Jason Hine, MD

References

  1. Zahad, R. A new and rapid method for espistaxis treatmetn using injectable form of tranexamic acid topically: a randomized controlled trial. AJEM. 31 (2013)1389-1392.[Pubmed]

  2. Wand, O. Inhaled Tranexamic Acid for Hemoptysis Treatment. Chest. 2018; 154(6):1379-1384.[Pubmed]

  3. Schwarz, W. Nebulized tranexamic Acid Use for Pediatric Secondary Post-Tonsillectomy Hemorrhage. Annals of Emerg Med. in Press. [Pdf]

  4. Dietrich, S. Trick of the Trade: Topical Tranexamic Acid Paste for Hemostasis. ALiEM. https://www.aliem.com/category/clinical/tricks-of-the-trade/

  5. Mason, J. Epistaxis TXA Pack. EMRAP HD. May 2018

  6. Rezaie, S. TXA for Everyone: Inhaled TXA for Hemoptysis. RebelEM.

  7. Rezaie, S. Topical Tranexamic Acid for Epistaxis or Oral Bleeds. RebelEM