Should TXA be administered in traumatic arrest or medical arrest where hemorrhage is suspected?

There is no demonstrated benefit to administering tranexamic acid (TXA) in the setting of cardiac arrest, either traumatic or medical from exsanguination. In traumatic cardiac arrest, contemporary evidence emphasizes immediate correction of reversible causes, such as external hemorrhage control, chest decompression, pelvic stabilization, and resuscitative thoracotomy where indicated, rather than antifibrinolytic therapy; TXA is not included in current arrest algorithms, and its benefit in this scenario has not been established (Schober et al., 2024). For medical cardiac arrest precipitated by massive gastrointestinal bleeding, including variceal hemorrhage, the large HALT-IT randomized controlled trial found no reduction in death due to bleeding with TXA administration and identified increased risks of venous thromboembolism and seizures (HALT-IT Trial Collaborators, 2020). In cases of ruptured abdominal aortic aneurysm, a National Institute for Health and Care Excellence (NICE) evidence review reported no direct clinical studies supporting TXA during transfer or early management and advised against extrapolating trauma data to aneurysmal rupture because of diagnostic uncertainty and thrombotic risk (NICE, 2020). Collectively, available evidence does not support the use of TXA in cardiac arrest once other priorities are addressed; the focus should remain on established life-saving interventions and definitive hemorrhage control.

References

HALT-IT Trial Collaborators. (2020). Effects of a high-dose 24 h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): An international randomised, double-blind, placebo-controlled trial. The Lancet, 395(10241), 1927–1936. https://doi.org/10.1016/S0140-6736(20)30848-5

National Institute for Health and Care Excellence. (2020). Use of tranexamic acid during transfer of people with ruptured or symptomatic abdominal aortic aneurysm (NG156 Evidence review R). National Institute for Health and Care Excellence. https://www.ncbi.nlm.nih.gov/books/NBK556906/

Schober, P., Giannakopoulos, G. F., Bulte, C. S. E., & Schwarte, L. A. (2024). Traumatic cardiac arrest: A narrative review. Journal of Clinical Medicine, 13(2), 302. https://doi.org/10.3390/jcm13020302