Tranexamic Acid (TXA) Trial Study Inclusion Criteria Review July 2015

Inclusion Criteria for Prehospital Providers Patients must meet trauma triage criteria related to anatomic, physiologic, and mechanism of injury as established by REMSA. Refer to REMSA Policy 5301- Trauma Triage Indicators and Destination Inclusion Criteria for Prehospital Providers

Pathophysiology of hemorrhagic shock As volume loss continues, O2 delivery and O2 consumption are mismatched. Anaerobic metabolism increases causing cell damage and eventual cell death. Pathophysiology of hemorrhagic shock

Pathophysiology of Hemorrhagic Shock DO2crit – oxygen delivery content available for circulation compared with VO2 (O2 consumption). Therapeutic goals: maintain circulating blood volume, reverse tissue hypoxia Pathophysiology of Hemorrhagic Shock

TXA can decrease the severity of the hemorrhage by preventing clot breakdown  helps maintain circulating blood volume Given within the first 3 hours can decrease mortality from hemorrhage – time matters! Tranexamic Acid

Inclusion Criteria for Prehospital Providers There are two types of patients who should receive prehospital TXA: Patient Type #1: An adult critical trauma patient with any sustained blunt or penetrating trauma within three (3) hours with signs and symptoms of hemorrhagic shock: - With Systolic blood pressure of less than 90 mmHg at scene of injury, during ground medical transport, or on arrival to designated trauma centers. TEACHING NOTES: Must have blunt or penetrating trauma meeting ICEMA Trauma Triage Criteria ICEMA Reference # 15030 Injury must have happened within the 3 hour window. Must show signs/symptoms of hemorrhagic shock SBP<90. DOCUMENT IT! Inclusion Criteria for Prehospital Providers

Inclusion Criteria for Prehospital Providers cont’d Or Patient Type #2: Adult critical trauma Patient with any sustained blunt or penetrating injuries within three (3) hours with signs and symptoms of hemorrhagic shock who are considered to be “high risk” for hemorrhage: - EBL > 500 mL in the field with HR > 120 - Bleeding uncontrolled by direct pressure or tourniquet - Major amputation of any extremity above wrist or ankles TEACHING NOTES: Must have blunt or penetrating trauma meeting ICEMA Trauma Triage Criteria ICEMA Reference # 15030 Injury must have happened within the 3 hour window. Must show a risk for hemorrhage. Document the criteria that it fits. DOCUMENT IT! Inclusion Criteria for Prehospital Providers cont’d

REMSA 5801

Don’t forget to document the armband number The green armband is the tracking of the patients both prehospital and hospital. Please document on the ePCR.

Seconds count! Do not delay TXA administration, even if you are at the back door of the trauma center. TXA administration may not happen immediately in the ER, delays can quickly add up to 30 minutes or more! Follow the inclusion criteria! When in doubt, contact trauma base hospital. Record full blood pressures – systolic and diastolic to assess patient’s response to therapy and the degree of hemorrhagic shock. TEACHING NOTES: Remember, TXA can be given prior to contact, if the patient meets the TXA administration inclusion criteria. Teamwork and cooperation are paramount to the success of this trial study. We all must work together to administer the TXA ASAP. (That means all hands on deck!) The inclusion criteria must be strictly adhered to. If there are any questions, do not delay TRAUMA base hospital contact. TXA Pearls of Wisdom

TXA is for hemorrhaging or at risk for hemorrhaging patients with blunt or penetrating trauma ONLY! (Isolated GI bleeds, nose bleeds, post-surgical bleeds and post-partum bleeds etc. are not included in this study) Remember to document pre-, during, and post- TXA administration vital signs, temperature and EBL SBP and DBP need to be included throughout PCR. Describe patient situation in PCR and in trauma base report TEACHING NOTES: For the purposes of the trial study, TXA is ONLY indicated for trauma patients that meet the inclusion criteria. It is NOT appropriate to obtain a base hospital order for TXA--even if you have it and can give it. Any deviation from this will jeopardize ICEMA’s ability to participate in this trial study. If you didn’t document it; you didn’t do it. So DOCUMENT IT! No exceptions. Tell the story, describe in detail the incident, assessments and interventions. TXA Pearls of Wisdom

Exclusion Criteria Any patient under 18 years of age. Any patient with an active thromboembolic event (within the last 24 hours), i.e., active stroke, myocardial infarction or pulmonary embolism. Any patient with a hypersensitivity or anaphylactic reaction to TXA. Any patient more than three (3) hours post injury. Exclusion Criteria

Traumatic arrest with greater than five (5) minutes of CPR without return of vital signs Penetrating cranial injury Traumatic brain injury with brain matter exposed Isolated drowning or hanging victims Documented cervical cord injury with motor deficit Exclusion Criteria

Administer TXA 1 gm in 100 ml of NS via IV/IO over 10 minutes. (Do not administer IVP. This will cause hypotension.) Remember to flush the tubing TEACHING NOTES: No IV push! Flushing the tubing will ensure that the patient received all of the medication. TXA Administration

We appreciate our EMS providers and Trauma Centers for participating in this study!!! Thank you all for your cooperation!