Background:

• TXA, tranexamic acid, is a lysine analog that binds to plasminogen on it's receptor sites, causing a conformational change in turn preventing fibrinolysis and stabilizing existing clot

Trauma : 

• It came into vogue after the MATTERS trial (https://www.ncbi.nlm.nih.gov/pubmed/22006852) in 2012 showed that it had a NNT of 7 to save a life in the military setting
• In a multinational, multicenter, 20,000 patient trial, CRASH 2, civillian trauma patients had an NNT of 67 for a life saved (https://www.ncbi.nlm.nih.gov/pubmed/21724564)

Epistaxis: 
TXA has been used for years by ED docs for epistaxis, but the data remains unclear

Study 1: Tibbelin A., Aust R., Bende M. et al. (1995) Effect of local tranexamic acid gel in the treatment of epistaxis. ORL 57, 207–209.  

• This study was done in 1995 in Sweden and was an underpowered, minimally followed up study of 68 patients
• Showed non significant differences in epistaxis severity and continuation with epistaxis. 

Study 2: Zahed R., Moharamzadeh P., AlizadehArasi S. et al. (2013) A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial. Am. J. Em. Med. 31, 1389–1392 (https://www.ncbi.nlm.nih.gov/pubmed/23911102)

• Based in Iran a randomized, placebo controlled sample with a power calculated, size of 216 patients 
• A predominance of patients with prior epistaxis in the intervention group which was the only confounder 
• Results showed an impressive difference in significant control in rebleeding, discharge times and increased patient satisfaction with TXA 

Future Considerations:

• There is some poor data that it can work in massive hemorrhage due to post partum hemorrhage. Keep an eye open for the WOMAN trial, concluding enrollment now
• There is also some data suggesting that it may work in massive GI Bleed, the HALT-IT trial is currently enrolling

Dosage: TXA for massive hemorrhage in trauma patients: give 1 gram over 10 ten minutes within the first 3 hours from the trauma. Follow it with another 1 gram over the next 8 hours.