TXA's role in Prehospital Post Partum Hemorrhage (PPH) ​

A common question we've been receiving is whether or not TXA has a role in prehospital management of PPH​

Can I complete a BHP Patch to administer TXA in the setting of PPH ? ​

TXA is currently reserved for cases of traumatic hemorrhage within the Traumatic Hemorrhage Medical Directive in the ALS PCS v5.4. This does not include PPH. ​

Currently, a BHP patch is not advised for TXA in the setting of PPH. Let's explore why

Evidence for TXA in Prehospital Trauma:

STAAMP Trial (Randomized Control Trial of prehospital trauma patients who receivedTXA vs placebo)​

• Patients who received TXA had lower 30day mortality than those who received placebo (8.1% vs 9.9%)​
• Found no increased risk of thrombotic events

​Evidence for TXA in Prehospital PPH:​

(none)​

It is still unknown if TXA in post-partum hemorrhage reduces mortality while avoiding significant clotting complications (DVT, PE, ACS, CVA)​​ that are at increased risk in pregnancy​

What is proven for PPH in prehospital care?​

Oxytocin is the first-line agent in PPH prehospitally as well as in-hospital. Followed by other medication/interventions in-hospital OR trained maneuvers also performed by Paramedics.​

But I've seen TXA being used in the ED or OB Floor...​

• There IS in-patient evidence, when used in conjunction with oxytocin + other resuscitation (blood products) + hemorrhage control maneuvers​
  • The WOMAN (WOrld Materna lANtribrinolytic) Trial (Lancet 2017) was an RCT of TXA vs placebo for in-hospital management of PPH in 21countries around the world​
  • Death due to bleeding was reduced with TXA (1.2% vs 1.7%)​

​TXA in-hospital is just one piece of PPH management​

The authors stress that TXA administration should not replace ABC's, addressing the 4 T’s/tinkle, and administering blood products as needed.​

FACT: Tone accounts for 70% of PPH post delivery; Oxytocin encourages uterine tone ​

Pre-hospital management of PPH should focus on what we know works​

• ABCs​
  • For C, when managing hemorrhage, consider:​
    • Have you given oxytocin yet?​
    • Natural ways to stimulate oxytocin (if able):​
      • Newborn latching​
      • Skin-to-skin​
      • Nipple stimulation (by patient to self)​
    • Maneuvers to reduce bleeding​
      • Placenta in: Bimanual compression​
      • Placenta out: Fundal massage​
    • IV access and bolus, if applicable​
    • Expedient transport​

In Summary​

• TXA is currently only for use in prehospital traumatic hemorrhage​
  • This is the only prehospital evidence-backed indication​
• In-hospital treatment of PPH may include TXA​
  • Only in-conjunction with other hemorrhage management​
  • Evidence-proven for in-hospital only​
• Prehospital management of PPH:​
  • Focus on managing hemorrhage with:​
    • Oxytocin 10 U IM ​
    • Natural oxytocin release techniques​
    • Maneuvers to simulate uterine tone and tamponade bleeding​
• TXA may one day become a prehospital treatment of PPH, but not at this time​

No additional resources available for this #SWORBHPTip.