SGEM#301: You Can’t Stop GI Bleeds with TXA

Date: September 16th, 2020 Guest Skeptics: Dr. Robert Goulden and Dr. Audrey Marcotte are Chief Residents from the Royal College of Emergency Medicine Program at McGill University. Robert’s academic interests include research and evidence-based medicine. Alongside his EM residency, he is doing a PhD in epidemiology. Audrey’s academic interests include trauma and resuscitation. Outside of medicine, Audrey likes to play rugby and run. Reference: Roberts et al. Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial. The Lancet 2020 This was an SGEM Journal Club episode recorded live at McGill University Grand Rounds. This was the third time coming to McGill University Department of Emergency Medicine to give Grand Rounds. The first visit was back in 2013 for SGEM#50: Under Pressure - Vasopressin, Steroids and Epinephrine in Cardiac Arrest. The bottom line was this was interesting, but VSE protocol was not ready for routine use. The second visit was SGEM#176: Somebody’s Watching Me – Cardiac Monitoring for Chest Pain. We were trying to answer the question: Do all patients presenting to the emergency department with chest pain need to be placed on cardiac monitoring or could some be safely removed? The SGEM Bottom Line was that for some patients presenting with chest pain who are chest pain free and have normal/non-specific ECG findings could potentially be safely removed from cardiac monitoring using the Ottawa CPCM Rule. Five Rules of SGEM-JC Case:A 58-year-old man presents with hypotension, tachycardia, and pallor. He vomits a large amount of bloody emesis and has epigastric discomfort. He is not taking any anti-coagulants. He remains hemodynamically unstable despite initial resuscitation and has another episode of hematemesis in front of you. While waiting for your consultant to answer the phone, you consider treating him with tranexamic acid (TXA), but wonder if it will prevent death from gastrointestinal (GI) bleeding. Background: We have covered the use of TXA a number of times on the SGEM. TXA is an anti-fibrinolytic agent that inhibits clot breakdown and has demonstrated mixed results in different clinical settings. The CRASH-2 trial showed a 1.5% absolute mortality benefit with TXA in adult trauma patients compared to placebo (SGEM#80). TXA also seems to improve patient-oriented outcomes in epistaxis (SGEM#53 and SGEM#210). However, TXA did not show a statistically significant difference for the primary outcome in post-partum hemorrhage (SGEM#214) WOMAN Trial, hemorrhagic stroke (SGEM#236) or traumatic intracranial hemorrhage (SGEM#270) CRASH-3. A Cochrane systematic review and meta-analysis of eight smaller trials (n=1,701) using TXA in gastrointestinal bleeding suggested a large (40%) risk reduction in all-cause mortality (Bennett et al 2014). However, even a meta-analysis is prone to bias and is only as good as the quality of the included trials. When all participants in the intervention group with missing outcome data were included as treatment failures, or when the analysis was limited to trials with low risk of attrition bias the mortality benefit of TXA disappeared. Clinical Question: Does treatment with TXA reduce the mortality of patients with upper or lower GI bleeds? Reference: Roberts et al. Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial. The Lancet 2020 Population: Adult patients (16 years of age or 18 years of age and older depending on country) with significant upper or lower GI bleed. Significant bleed was defined clinically (judged at risk of bleeding to death, hypotension <90 mmHg systolic, tachycardia,