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Jeff -I agree that earlier is probably better with TXA but that will
undoubtedly lead to indication creep, overuse, and likely an unacceptably
high complication to 'save' ratio. This is the same problem with
essentially all pediatric severe disease and potential therapies with a
higher than average risk profile.
Jay

On Thu, Nov 29, 2018 at 1:33 PM Jeff Myers, DO, EdM <[log in to unmask]>
wrote:

> Good examples of TXA use that are outside traditional trauma indications.
>
> Trials aside, wouldn't it be better to initiate earlier, rather than as
> the last ditch effort after significant blood (and coagulation factor)
> loss? When I work at outlying hospitals with adults I initiate after
> first episode of hypotension, if the blood pressure is labile or if the
> bleeding site is non-compressible (GSW to torso, high energy MVC, GI
> Bleed, etc).
>
> Thanks,
> Jeff Myers, DO, EdM, EMT-P, FAEMS
> Buffalo, NY
>
> On 11/29/2018 12:05 PM, Jay Fisher wrote:
> >   For what it is worth we have used TXA twice in the last two years for
> > children with life threatening, non traumatic, bleeding at a dose of 10
> > mg/kg and in one case it may have helped and the other it definitely did
> > not. Our indications were - 'I think this child is going to bleed to
> death'
> > and we were initiating the massive transfusion protocol on both of them.
> > One of them was a 5 yo girl who was a week post-op from T and A and on
> her
> > first day of kindergarten began vomiting at school and then began
> bleeding
> > profusely (talk about PTSD!). She went to an outlying hospital and then
> to
> > us. On arrival she had more massive bloody vomiting and was pale, altered
> > and hypotensive. We gave blood and fluids and TXA 10 mg/kg. She got to
> the
> > OR quickly and had stopped bleeding when the ENT got a look at the
> pharynx.
> > The other child was a 9 yo with cavernous malformation of the portal
> vein,
> > portal htn, varices and hypersplenism who was a week s/p banding for
> > varices and began to have massive bleeding. He was awaiting insurance
> > approval for a TIPS procedure out of state. He was pale, hypotensive and
> > altered as well. Massive transfusion protocol was initiated and he was
> > given TXA 10 mg/kg. It didn’t help. He went to the OR quickly as well but
> > it took hours for the team to get the bleeding to completely stop. He
> went
> > through a blood volume and a half. He survived and wsa transported and
> got
> > his TIPS a few days late.
> >
> > Jay Fisher MD FAAP FACEP
> > Peds EM
> > Children's Hospital of NV at UMC
> > UNLV SOM
> >
> > On Wed, Nov 28, 2018 at 11:56 AM Howard, John <
> > [log in to unmask]> wrote:
> >
> >> Good afternoon:
> >>
> >> Our institution is evaluating the utilization of Tranexamic acid (TXA)
> for
> >> our pediatric massive transfusion protocol.
> >>
> >> Could any of you elaborate how your group determines TXA usage in
> patients
> >> under 16 years?  There is sparse literature available and many
> hospitals do
> >> not include it in their MTP’s.  Many non-trauma indications include
> spinal
> >> surgeries, craniosynostoses, CV surgeries, etc.
> >>
> >> This article may be somewhat helpful:
> >>
> https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4912435/pdf/nihms759080.pdf
> >>
> >> I’d appreciate any feedback—thanks!
> >>
> >> John M. Howard, DO
> >> Pediatric Emergency Medicine
> >> Advocate Children’s Hospital
> >>
> >>
> >>
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> --
> Jeff Myers, DO, EdM, EMT-P, FAEMS
> Emergency Care Physician and Educator
> Buffalo, NY
>
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>                  http://listserv.brown.edu/ped-em-l.html
>


-- 
Jay D. Fisher MD FAAP FACEP
Clinical Professor of Pediatrics and Emergency Medicine
UNLV School of Medicine
Medical Director, Pediatric Emergency Services
Children's Hospital of Nevada at UMC

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