|
Author |
Bryson Galozo |
Date |
2020-11-29 |
|
Reviewer |
Jennie Helmer |
Edited |
2020-12-16 |
You and your partner are dispatched to a 56-year-old male experiencing profuse hematemesis. On arrival, you find the patient crouched over his toilet bowl. The water in the toilet is coloured bright red. The patient explains that he has been vomiting bright red blood for the past hour and has been unable to stop. You note that his skin is pale and cool. His vital signs indicate hypovolemic shock with a pulse of 128 and a blood pressure of 88/50.
After preparing your patient for transport and establishing IV access, you consider the administration of tranexamic acid as you know that it is beneficial for patients with signs of hypovolemic shock following trauma. You wonder if it would benefit your current patient who is experiencing hypovolemic shock due to an upper GI bleed.
“In patients with acute GI bleeds, does the administration of TXA compared to the non-administration of TXA reduce patient mortality?”
|
Population |
Adult patients with an acute GI bleed and signs of shock |
|
Intervention |
Administration of TXA |
|
Comparison |
Non-Administration of TXA |
|
Outcome |
Patient Mortality |
PubMed: ((Txa OR Tranexamic acid) AND GI Bleed AND Mortality)
7 Results (5 Relevant) on 2020-11-27
Tranexamic acid is an anti-fibrinolytic that helps prevent clot break-down within the body. It prevents the conversion of plasminogen into plasmin, which in turn prevents plasmin from breaking down the fibrin structures important for coagulation (Chaucey & Wieters, 2020). The hope is that in preventing clot degradation, occult bleeding can be minimized thus reducing patient mortality.
Currently, tranexamic acid is used by BCEHS paramedics in cases of trauma when there are signs of shock and the possibility of occult bleeding. The CRASH-2 trial has demonstrated the effectiveness of this medication when it is administered within three hours of bleeding onset (2013). Notably, patients who receive tranexamic acid within the above-mentioned time frame show a marked decrease in all-cause mortality (2013).
It may be theorized that tranexamic acid’s mechanism of action could prove beneficial in cases of GI bleeding with signs and symptoms of shock. A 2014 Cochrane review involving eight randomized controlled trials studying the effects of tranexamic acid on mortality in the case of GI bleeding suggested that tranexamic acid is beneficial in reducing mortality. Unfortunately, the trials included in the review are all small scale (n = 47-216; median = 204) and many include sources of bias (ex: inability to follow up with participants). The author’s write that the, “review found that tranexamic acid appears to have a beneficial effect on mortality, but a high dropout rate in some of the trials means that we cannot be sure of this until the findings of additional research are published (2014)” Unfortunately, as noted by the authors, the quality of evidence is far from conclusive and the question remains as to whether tranexamic acid provides mortality benefits to patients with GI bleeding.
The papers reviewed show mixed results, with some demonstrating a reduction in mortality (Barer et al., 1983; Bergqvist, Dahlgren, & Hessman, 1980) and others demonstrating no notable effect with tranexamic acid administration (HALT-IT, 2020; Smith et al., 2018; Biggs, Hugh, & Dodds, 1976). Unfortunately, the majority of the papers (excluding the HALT-IT trial) had small sample sizes and spanned few centres, thus lowering the strength of evidence.
The most robust study (and the strongest evidence available) is the recently published HALT-IT trial, an RCT involving 12,009 subjects across 164 hospitals in 15 countries. The HALT-IT trial demonstrated no statistically significant difference in mortality rates between patients administered tranexamic acid vs. patients administered a placebo. Importantly, the HALT-IT trial noted that the group given tranexamic acid had a higher incidence of venous thromboembolic events (DVT or PE) in comparison to the placebo group.
In patients experiencing signs of hypovolemic shock in association with a GI bleed, the strongest evidence currently suggests that tranexamic acid is of no benefit and may even be associated with harm. At this time, paramedics should not administer tranexamic acid for GI bleeds.