TXA & anticoagulant/antiplatelet reversal

Indications

• Significant haemorrhage and SBP <90mmHg or HR >110bpm.
• At risk of significant haemorrhage.

Relative Contraindication

• History of thromboembolic disease.
• >3 hours from injury unless hyperfibrinolysis is demonstrated on ROTEM.

Administer 1g bolus over 10 minutes followed by 1g infusion over 8 hours.

The infusion can be omitted/stopped in the following patients:

• No evidence of haemorrhage or
• Haemorrhage controlled with a normal ROTEM.

Local guidance for RHCYP Edinburgh

Indication: to be administered within 3 hours of injury to:

• Any child who requires RCC transfusion within 3 hrs of injury.
• Any child considered (by the treating clinician) to be at significant risk of major bleeding (e.g. liver lac, splenic lac), especially if being managed conservatively.

Dosage:

• Loading dose – 15mg/kg (max 1g) diluted in a convenient volume of sodium chloride 0.9% or glucose 5% and given over 10 minutes.
• Maintenance infusion – 2mg/kg/hour.  Suggested dilution 500mg in 500ml of sodium chloride 0.9% or glucose 5% given at a rate of 2mls/kg/hour.  For at least 8 hours or until bleeding stops.

Reference

Evidence statement: Major trauma and the use of tranexamic acid in children, RCPCH, November 2012.

• An INR and an APTTR of ≤1excludes the presence of significant levels of novel anticoagulants in most patients.
• Patients on warfarin should be reversed unless the bleed is extremely small and the procoagulation risk is high.
• Reversal should occur within one hour of decision to reverse.
• Please refer to local guidelines for warfarin/NOAC reversal policies

Advanced age is not an absolute predictor of poor outcomes following trauma and should not be used as the sole criterion for denying or limiting care.

Resources for managing patients who refuse blood (including Jehovah’s Witnesses) is available from NHS Lothian Policy Online.