The administration of life-saving interventions during the critical prehospital phase of emergency care can significantly impact outcomes for trauma patients. One such intervention at the forefront of current emergency medicine research is the prehospital use of tranexamic acid (TXA) to mitigate hemorrhage and improve survival rates. A recent 1:1 matched comparative study conducted at a level 1 trauma center has shed new light on the potential benefits and risks associated with prehospital TXA administration.
The study, published in the American Journal of Emergency Medicine (AJEM), aimed to test the efficacy of prehospital administration of TXA on mortality, thromboembolic events, and the need for blood transfusion in trauma patients. Conducted between January 2017 and September 2018, the research involved a retrospective comparison of adult trauma patients who received TXA before arriving at the hospital with those who did not but were transfused within four hours of admission.
The DOI for this influential article is 10.1016/j.ajem.2019.04.051, and it showcases the collaborative efforts of scholars from Hamad General Hospital (HGH) in Doha, Qatar, including El-Menyar Ayman, Sathian Brijesh, Wahlen Bianca M., Abdelrahman Husham, Peralta Ruben, Al-Thani Hassan, and Rizoli Sandro.
The study included a total of 204 patients (102 in the TXA group and 102 in the control group), each meticulously matched for age, sex, injury severity, head injury scores, and prehospital heart rate and blood pressure, to ensure valid comparisons.
Upon admission, the researchers observed that the shock index, a potential indicator of circulatory collapse, and serum lactate levels, a measure of metabolic disruption, were noticeably higher in the control group. Conversely, the TXA group showed a statistically significant decreased likelihood (odds ratio [OR] of 0.44) of having a shock index of 0.9 or higher.
Moreover, the median amount of blood transfusion required was substantially higher in the control group compared to the TXA group. Interestingly, there was a marked reduction in the need for massive blood transfusion protocols in the TXA group, with an odds ratio of 0.35.
Although the study reported a higher occurrence of venous thromboembolic (VTE) events in the TXA group, this increase did not reach statistical significance, suggesting no clear link between TXA use and thromboembolic risk in this context. Equally, while the overall mortality rate was lower in the TXA group, it didn’t meet the threshold for statistical significance, indicating the need for further studies with larger populations.
This research underscores the potential of TXA as a powerful tool in reducing the need for in-hospital blood transfusion and MTP among trauma patients. Yet, its implications for mortality and thromboembolic event rates require more extensive clinical trials to provide conclusive evidence of its benefits and safety.
The investigation by El-Menyar et al. is not the first to explore the use of TXA in trauma care, but it is among the pioneering studies addressing its prehospital administration. Their findings align with earlier research that has supported the in-hospital use of TXA for bleeding trauma patients, including the notable CRASH-2 trial, which demonstrated reduced mortality with TXA treatment.
Keywords
1. Prehospital TXA trauma
2. Tranexamic acid emergency medicine
3. Trauma patient blood transfusion
4. TXA shock index outcome
5. Trauma care thromboembolic risk
References
1. El-Menyar, A., Sathian, B., Wahlen, B. M., Abdelrahman, H., Peralta, R., Al-Thani, H., & Rizoli, S. (2020). Prehospital administration of tranexamic acid in trauma patients: A 1:1 matched comparative study from a level 1 trauma center. The American Journal of Emergency Medicine, 38(2), 266-271. https://doi.org/10.1016/j.ajem.2019.04.051
2. CRASH-2 trial collaborators. (2010). Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant hemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet, 376(9734), 23-32. https://doi.org/10.1016/S0140-6736(10)60835-5
3. Morrison, J. J., et al. (2012). Prehospital low-dose tranexamic acid administration for war-related injury. The New England Journal of Medicine, 367, 227-235. https://doi.org/10.1056/NEJMoa1203724
4. Como, J. J., et al. (2015). The role of tranexamic acid in trauma care. Journal of Trauma and Acute Care Surgery, 79(4), S76-S79. https://doi.org/10.1097/TA.0000000000000688
5. Perkins, Z. B., et al. (2015). Meta-analysis of prognostic factors for amputation following surgical repair of lower extremity vascular trauma. British Journal of Surgery, 102(5), 436-450. https://doi.org/10.1002/bjs.9731
Despite its promising results, the authors of the AJEM article advocate for the necessity of larger-scale clinical trials to definitively ascertain the efficacy and safety of TXA in the prehospital setting. The promise of reducing the requirement for blood transfusion and potentially lowering mortality rates holds immense potential, but as with all medical interventions, a balanced understanding of the benefits and risks is paramount in delivering superior patient care. The emergency medical community continues to await further evidence to fully embrace prehospital TXA administration as standard practice in trauma care.