Critical Care Medicine-Neurologic Disorders>>>>>Management Strategies (Coagulation, Vasoactive Medications)
Question 3#

A 29-year-old male is hypotensive in the emergency department after a motor vehicle accident 2 hours ago despite fluid resuscitation. You suspect intra-abdominal hemorrhage and have heard that tranexamic acid may reduce mortality and death from hemorrhage. You decide to administer tranexamic acid knowing the possible complications from it.

How is tranexamic acid metabolized?

A. Renal
B. Liver
C. Lungs
D. Plasma esterases
E. CYP 450

Correct Answer is A

Comment:

Correct Answer: A

Antifibrinolytics (aminocaproic acid, tranexamic acid, and aprotinin) inhibit fibrinolysis by binding to the plasminogen and inhibiting the formation of plasmin and displacing plasmin from fibrin. The CRASH-2 trial demonstrated that the tranexamic acid group had lower mortality and death from hemorrhage, with no differences in vascular occlusion complications. Tranexamic acid was further evaluated in the ATACAS trial in cardiac surgery which showed no difference in rate of thrombotic complications (myocardial infarction, stroke, pulmonary embolism, renal failure, or bowel infarction). Tranexamic acid is metabolized by the kidneys, and there is concern for a higher risk of seizures among patients with renal failure receiving tranexamic acid.

References:

1. Levy JH, Koster A, Quinones QJ, Milling TJ, Key NS. Antifibrinolytic therapy and perioperative considerations. Anesthesiology. 2018;128(3):657-670
2. CRASH-2 trial collaborators; Shakur H, Roberts I, Bautista R, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 2010;376:23.
3. Myles PS, Smith JA, Forbes A, et al. Tranexamic acid in patients undergoing coronary-artery surgery. N Engl J Med. 2017;376:136.