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Tranexamic acid use in Canadian hospitals

Armymedic

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full article:
http://www.theglobeandmail.com/life/health/new-health/health-news/hospitals-shun-cheap-drug-used-to-stop-bleeding/article2430657/


May 11, 2012
Hospitals shun cheap drug used to stop bleeding
By LISA PRIEST
Globe and Mail Update
Used by armies on battlefield, generic TXA costs $8 and could save 217 Canadians yearly

One of the cheapest medical interventions to help stop bleeding - an $8 generic drug by the name of tranexamic acid (or TXA) - is rarely used by Canadian hospitals, even though it could save hundreds of trauma patients each year.

TXA has been sold for years over the counter in Britain to women with heavy menstrual bleeding and also in Japan to those with sore throats. It is believed to work by blocking plasmin, an enzyme that dissolves blood clots. The World Health Organization added it to its essential drugs list last year, and British and American armies have adopted it. Canada went a step further, deploying it with medics in the battlefield.

Ian Roberts, clinical trials director for the London School of Hygiene and Tropical Medicine and leader of a 2010 Crash-2 trial for TXA, has found that the drug could save an estimated 217 lives in Canada each year, if provided within three hours. And it can be done at a remarkably low cost: $8 per patient, or $12 if you throw in the tubing and IV needle required to infuse the drug.

Yet despite saving Canadian lives on the battlefield, the drug has been adopted slowly in Canada's emergency wards. Figures from IMS Health Brogan, a private company that tracks prescription drug spending, show sales of TXA to Canadian hospitals has actually dipped slightly, from $7-million in 2009 to $6.9-million in 2011.

The first use should be be the paramedics and the prehospital providers in the field. The CRASH-2 proves that the most effective time for administration is before 3 hours post injury, with a significant benefit if started within the first hour.

We have it in the CF and it will be coming to the Med Techs soon, but it is surprising how few MOs outside of the trauma world have heard of it.
 

mariomike

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Rider Pride said:
The first use should be be the paramedics and the prehospital providers in the field. The CRASH-2 proves that the most effective time for administration is before 3 hours post injury, with a significant benefit if started within the first hour.

As we know, each province has their own way of doing things.

Like every other service, Toronto - I use it as an example because it is the only service I am familiar with - will have to decide if tranexamic acid is to be used by their PCPs & ACPs under FTT guidelines.

"FIELD TRAUMA TRIAGE ( FTT ) GUIDELINES:
Transport time ( to a Trauma Centre - mm ) should be less than 30 minutes. If transport time is greater than 30 minutes, despite the presence of indicated criteria, the patient should be transported to the closest receiving hospital."

Transport time to the closest receiving hospital would be less than 30 minutes.

Some patients may fall into the "Load and Go" category.

The receiving hospitals may wish to consider ordering Tranexamic acid, if they have not already.

T-EMS can usually get FTT patients inside a Level- 1 trauma centre ( St. Michael's, Sunnybrook or Sick Kids ) within the so-called "Golden Hour" of when the 9-1-1 call is received. ( They do not use the term "Golden Hour" as much as we used to. )
Scene time should not exceed ten minutes, unless extenuating circumstances ( extrication, triage of multiple patients ) exists. You also have to add Response Time to the scene.

FTT pregnant patients ( over 20 weeks gestation ) also require special consideration.

Tranexamic acid may be more of a necessity out of town:
http://healthydebate.ca/2011/08/topic/politics-of-health-care/trauma-part-2
"There is, however, wide variation in how long it takes to get a severely injured patient to a trauma centre in Ontario."

The Base Hospital physicians may, or may not, decide to treat Tranexamic acid like they did Quikclot. Last I heard, of the 72 land ambulance services in Ontario, only Algoma paramedics carry it for their most remote communities that do not have a receiving hospital nearby.

On the subject of controlling blood loss, I recall similar debate on the job in the 1970's regarding the benefit of Medical / Military Anti-Shock Trousers (MAST) and before I retired, about combat arterial tourniquets ( CAT ) in EMS.

I am not an SME. Just a retired person with an interest in the topic.

Regards,
mm





 
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My experience is that civilian emergency medicine is afraid of hemostats and coagulation adjuncts.  I remember back in Ontario asking a supervisor if Celox would ever be considered for Paramedic use where I was working in the future.  His first response was "whats that"?  After I explained how hemostats work and what I had seen them do in the past he just kind of gave me a blank stare and told me that he thought it wasn't practical for EMS.  I have also received the same type of reaction from some doctors on the subject.  Hopefully twenty years from now they will realize how simple they are and how many lives could of been saved by using them, but I am sure by then we will have some type of lasers or some other far out way of dealing with hemorrhage in the field.
 

medic45

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We have been using TXA in the BCAS for a year and a half.  We administered the first prehospital case within Canada.  It is currently deployed at the CCP level for air and ground responses.  The most uses occur (obviously) on helicopter autolaunches for trauma.  There is a good chance we will see it at the ACP level soon as well.
 

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BC, meaning Vancouver General Hospital, is one of the provinces leading in Trauma research in Canada.

Not coincidently, it is one of the three big trauma hospitals where military surgeons and others have trained ( including myself).
 

mariomike

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medic45 said:
We have been using TXA in the BCAS for a year and a half.

ETA to a Level 1 trauma centre will likely be a factor in any forthcoming medical directives from the Base Hospitals to their paramedics. 

In Metro Toronto, FTT patients are transported directly by land ambulance ( without stopping at a receiving hospital en route ) from the scene to Level 1 adult or pediatric trauma centres.

ETA at a trauma centre may vary elsewhere:
From the quoted article in the original post, "... the mean time for a patient to reach a trauma centre has been reported to be up to 6.7 hours in Ontario; 7.5 hours in Nova Scotia and 10.5 hours in Quebec."

On the subject of our attempts to control blood loss over the years, we used MAST. We have one gathering dust in our museum as a medical curiosity.
"The MAST Will Not Die":
http://www.ems1.com/ems-products/apparel-accessories/articles/392087-The-MAST-Will-Not-Die

"MAST Again: Medical, Not Military Anti-Shock Trousers":
http://www.ems1.com/ems-products/consulting-management/articles/398415-MAST-Again-Medical-Not-Military-Anti-Shock-Trousers




 

medicineman

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I guess the issue is this - Has Health Canada granted anything other than a Special Access Exemption to the military for using these agents?  If they haven't, until they do, they won't be used in Canadian hopsitals/EMS systems...for other than study purposes.  Once there have been enough cases in the "real world" and shown to be effective and safe, they'll likely be licensed and eased into service. 

MM
 
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