Making the Case for EP Medical Providers to Carry TXA in their Medical Bags

Imagine you are a lone EP Medic tasked to accompany your client for their 2-week trip to a remote destination, be it a cabin in Alaska, a ranch in Wyoming, a yacht trip to St Barts, or an Arican safari. Your client and their family count on you for their safety and medical treatment. During client coverage, an incident occurs; it could be a jet-ski accident, a vehicular accident on safari, getting bucked off a horse at a remote ranch, or a snowmobile accident in Alaska, all of which can have delayed transport times ranging from 2-10 hrs for definitive care. Now let us talk about the patient: you, as the medic, medical bag in hand, are with the client at the time of the incident. During the initial assessment, your patient has a very tender abdomen with abdominal wall bruising and flail chest segment. No further injuries are observed, and no significant bleeding is visible. Moving to your secondary assessment, you check your patient’s vitals. He is mildly tachycardic with a HR of 110, and his BP is lower than his baseline at 105/68. You have been with your patient for around 5 minutes at this point. What are you suspecting, and what interventions do you start with? Now you have been with your patient for 15 minutes; they are becoming cool, pale, and diaphoretic and are in trouble; their heart rate has increased to 130s, and their BP has dropped to 98/60. As the medic, suppose you are trained to do a FAST Scan (Ultrasound of the Abdomen) using your portable Butterfly IQ Ultrasound. In this case, you see free fluid in the hepatorenal recess or Morison pouch. What can you do next? What do you carry? Do you have TXA? Many may ask, what is TXA? 

Tranexamic acid, also known as TXA, is a drug with many uses that has attracted much attention in the medical community and has seen increased military and civilian utilization over the last decade. TXA was first made in 1962 by Japanese researchers and approved by the US Food and Drug Administration (FDA) in 1986. This article aims to give an overview of TXA, covering its mechanism of action, indications, contraindications, administration techniques, side effects, and how we can use it in the EP industry. 

What is the Mechanism of Action?

TXA effectively reduces bleeding by aiding in stabilizing and preserving pre-existing clots from breaking down. It is a synthetic lysine derivative and binds to the lysine-binding sites on plasminogen, preventing plasminogen from becoming the active form, plasmin, thus preventing the breakdown of blood clots.

Indications

TXA, in recent years, has been brought to the forefront of Pre-Hospital trauma due to its ability to aid in uncontrollable hemorrhage (aka bleeding in the box). However, TXA has multiple uses and is frequently used in surgical operations to control bleeding and lessen the need for blood transfusions. Additionally, TXA is widely administered to women because it is useful in controlling heavy menstrual bleeding. The treatment of hemophilia, a hereditary condition that inhibits blood coagulation, is another critical application. TXA aids in the prevention and management of hemophiliacs’ bleeding episodes by slowing clot disintegration.

Contraindications

There are a few reasons why medics should not use TXA in an uncontrolled hemorrhagic emergency. The patient has an allergy to TXA or any of its components, a history of a venous or arterial thrombotic event, suspected intracranial bleeding, or you believe the traumatic incident occurred more than 3 hours ago. 

Adverse Effects

Like any medication, TXA has potential adverse effects. The most common side effects reported include nausea, vomiting, and gastrointestinal disturbances. Rarely allergic reactions such as rash, itching, or difficulty breathing may occur. Uncommon but serious adverse effects include thromboembolic events, which can be life-threatening. Be sure to monitor the patients closely when administering TXA. Proper administration is essential to a positive patient outcome. 

How and why should we use TXA in EP? 

As professionals, we should strive to provide the best protection for our clients. Adding TXA to an EP medic bag provides a unique versatility that enhances comprehensive patient care. TXA’s versatile route of administration IV/IO/IM, nebulized to the topical application, provides the practitioners with multiple modes of hemorrhage control. The use of TXA ranges from massive hemorrhage control in a multisystem trauma patient to topical application for patients who have deep lacerations while on anticoagulants. TXA’s ability to inhibit clot breakdown combined with its minimal contraindications allows it to be written into protocols with minimal to no impact on the medical director’s medicolegal liability. 

Methods of Administration: While individual protocols may differ slightly, below are some of the most common uses and routes of administration. (Disclaimer: Please follow the protocols and/or policies & procedures of your local EMS agency and/or medical director if and when giving TXA or any regulated prescription medication.)

• IV/IO (Intraosseous): Primarily used in trauma or pre-surgical settings to prevent surgical hemorrhage. 
• IM Use: This is a new and developing use of TXA, mostly in military applications. 
• Topical: Can be used in minor and non-traumatic situations. 
• Oral: Given pre/post-operative to help with clotting
• Inhalation: Nebulized TXA may offer a hemostatic benefit and aid in stabilizing tonsillectomy hemorrhage and other nasopharyngeal and oropharyngeal hemorrhage.
• Nasal Packing: Gauze can be soaked in TXA and placed in the nasal cavity to stop bleeding

When giving TXA during a prolonged field care setting, where treatment times are longer and transport to a higher level of care is delayed, medics should continue to monitor hemodynamics and watch out for unwanted thromboembolic events.

Conclusion

In conclusion, tranexamic acid (TXA) is a versatile medication with a potent mechanism of action that inhibits clot breakdown. It is widely used in the medical industry and easily administered via various routes, including IV, topical, oral, inhalation, and nasal packing/atomization. TXA’s proven effectiveness in bleeding control and ease of use is undeniable.

It should play a significant role in the Security and EP industry when it comes to pre-hospital client care. 

Co-Author Shane Jenkins is the Medical Program Manager and specializes in travel risk management, Executive Protection, and Concierge Medicine for clientele that travels worldwide. He is a Nationally Registered Paramedic licensed in Florida, AHA Instructor, as well as an NAEMT Instructor. Shane’s experience provides a unique perspective on the security industry and client risk assessment.

Co-Author Michael Guirguis, MD, is an Emergency Room Physician and Chief Medical Officer at a company which provides consulting, medical direction, and oversight for private family office and corporate executive protection programs that perform domestic and international duties.