Tranexamic acid use in head injury

Tranexamic acid use in head injury

• for people with a head injury and a GCS score of 12 or less who are not thought to have active extracranial bleeding, consider (1):
  • a 2 g intravenous bolus injection of tranexamic acid for people 16 and over
  • a 15 mg/kg to 30 mg/kg (up to a maximum of 2 g) intravenous bolus injection of tranexamic acid for people under 16
    
    
  • give the tranexamic acid as soon as possible within 2 hours of the injury, in the pre-hospital or hospital setting and before imaging
    
    
• the NICE committee state:
  • people over 16
    • "..despite the uncertainty in the clinical evidence, there was a benefit with tranexamic acid in terms of reducing all-cause mortality and mortality from traumatic brain injury. They also considered that the evidence showed that it caused very few adverse events. Based on the evidence, they agreed that a 2 g intravenous bolus dose of tranexamic acid, given within 2 hours of a head injury and before imaging, could be considered for people 16 and over with moderate or severe traumatic brain injury. The committee recommended a 2 g intravenous bolus injection of tranexamic acid because this dose was found to be the most safe and effective.."
  • people under 16
    • "..Because of a lack of trial evidence for tranexamic use in people under 16, the committee used extrapolated evidence from the trials in adults, and their expertise and knowledge. In NHS clinical practice, a tranexamic acid dose of 15 mg/kg is used in people under 16 with extracranial injuries. But, in this age group, tranexamic acid is not currently widely used for isolated head injury and dosing is variable (15 mg/kg to 30 mg/kg). Evidence for people 16 and over with a head injury from a pre-hospital setting suggested that a 2 g dose of tranexamic acid reduced all-cause mortality (at 28 days and 6 months), with no evidence of negative effects. So, the committee concluded that it could recommend the equivalent of a 2 g dose of tranexamic acid for people under 16. They discussed that, based on the average weight of people 16 and over being 70 kg, a 2 g dose of tranexamic acid for people 16 and over would equate to a 30 mg/kg dose for people under 16. So, they concluded that a dose range of 15 mg/kg to 30 mg/kg was appropriate for people under 16.."
      
      
• this recommendation for the early administration of tranexamic acid in people who have experienced a head injury with significant impairment of consciousness
  • aims to reduce morbidity and mortality, even in the absence of suspected extracranial bleeding
  • consider an intravenous tranexamic acid bolus within 2 hours of injury in people with suspected moderate or severe traumatic brain injury, even when no extracranial bleeding is evident (2)

Reference:

• NICE (May 2023). Head injury - Triage, assessment, investigation and early management of head injury in children, young people and adults
• Rajesh S, Wonderling D, Bernstein I, Balson C, Lecky F. Head injury: assessment and early management-summary of updated NICE guidance BMJ 2023; 381 :p1130 doi:10.1136/bmj.p1130