Tranexamic Acid in Trauma Resuscitation: Can It Help?

When it comes to resuscitation, tranexamic acid likely isn’t the first medication to come to mind. As an anti-fibrinolytic medication that is FDA-approved to control bleeding in hemophilia, its use in resuscitation is considered off-label. But since it can help prevent coagulopathy in patients with severe hemorrhage, some responders in the field have started to turn to it in certain pre-hospital trauma resuscitation cases.

How does tranexamic acid work, what are the benefits and drawbacks, and when might it make sense to use it in trauma resuscitation? Keep reading to find out.

Tranexamic acid: How does it work?

Trauma triad

Emergency responders are all too familiar with the dreaded trauma triad of death: the combination of hypothermia, metabolic acidosis, and coagulopathy often seen in trauma patients. These three conditions are closely linked and can quickly compound and exacerbate each other, creating a vicious cycle that increases the likelihood of death. Trauma resuscitative care aims to offset this deadly combination, and tranexamic acid may be able to help. As an anti-fibrinolytic drug, tranexamic acid addresses the coagulopathy component of the triad.

A closer look at coagulopathy

In trauma cases, impaired clotting is related to ischemia and hypoxia brought on by the traumatic event. This results in hyper-activation of the body’s fibrinolytic response, leading to clot destruction instead of formation.

 How does tranexamic acid work?

During fibrinolysis, lysine allows plasma to bind to fibrin so it can break down the clot. Tranexamic acid works by blocking the binding site, preventing plasma from attaching to fibrin — and stopping the fibrin matrix.

The result? With the binding site blocked, fibrinolysis can’t occur, preventing the coagulopathy that can be so problematic during a massive hemorrhage.¹

Benefits and drawbacks of tranexamic acid

Benefits

Studies of tranexamic acid have underscored some of the potential benefits of its use in trauma care. For example, in the 2010 CRASH-2 study — a large, multi-center, double-blinded, controlled trial in which adult trauma patients were given either tranexamic acid or a placebo — patients who were given tranexamic acid within 3 hours of the event had an improved survival rate.² One year later, the retrospective MATTERS study attempted to validate the CRASH-2 study with an emphasis on combat trauma victims. Results there showed a decrease in mortality as well.³

Drawbacks

Although these studies are encouraging, tranexamic is not without risk. We know that it prevents the attachment of plasma to fibrin, allowing patients with severe hemorrhage to clot more to control the bleeding. But it’s a double-edged sword: Preventing fibrinolysis can also lead to unwanted blood clots, causing a plethora of other problems — like deep vein thrombosis, myocardial infarction, pulmonary embolism, or ocular occlusions — that can be detrimental to the patient’s survival.

The bottom line

Given these pros and cons, it’s not surprising that the American College of Surgeons includes references to tranexamic acid in its Advanced Trauma Life Support response — but stops short of full support. As it currently stands, early resuscitation with blood and various blood products as a Class III and Class IV recommendation is still the preferred method to treat shock and hemorrhage.⁴ But that doesn’t mean tranexamic acid doesn’t have its place. In cases where blood products aren’t readily available to pre-hospital responders, tranexamic acid may be an appropriate alternative — one that can help improve survival in trauma events.