Goal

Use medications to optimize the casualty’s ability to form blood clots.

TXA is an antifibrinolytic medication that helps to stabilize blood clots and may improve survival from hemorrhage. TXA should be administered for casualties with signs of hemorrhagic shock and all casualties who meet criteria for DCR within 3 hours of injury. TXA should not be given more than 3 hours after injury, because this has been associated with increased mortality.10,26,27

- Minimum: Administer TXA 2gm IV as soon as possible after injury (not more than 3 hours after injury).

Administration of undiluted TXA by slow IV push is acceptable if supplies or tactical situation prevent 100mL IV infusion. Ideally, slow IV push should be given over 10 minutes; however, it may be given faster when the tactical situation indicates, accepting the risk of transient hypotension. Use greater caution when the casualty is already hypotensive before TXA administration.

- Best: administer TXA as soon as possible (within 1 hour) after injury. Administer 2gm of TXA IV/IO ASAP, but NOT later than 3 hours

Calcium administration replaces serum calcium lost during hemorrhage and transfusion of citrated blood products. Calcium helps prevent cardiac dysfunction and hypotension.

- Minimum: Administer 1gm of calcium IV/IO during or immediately after transfusion of the first unit of blood product.
- Better: With ongoing resuscitation, give additional 1g of calcium after every four units of blood product.
- Best: Monitor serum calcium during ongoing resuscitation and administer 1g of calcium for ionized calcium less than 1.2mmol/L.

Caution: Calcium gluconate is safer for peripheral use. Calcium chloride may cause severe skin necrosis if extravasation occurs through a partially dislodged IV or IO catheter. The risk of bone necrosis with IO injection of calcium chloride is not known. When using peripheral IV or IO access, use extreme caution to ensure the device is in good intravascular position and no extravasation occurs.

Caution: Do not mix medications and blood products in the same IV line. Use a separate line or flush well between giving medications and blood products.