Assessing the clinical utilization of tranexamic acid by paramedics for patients with major trauma (ACUTE)

Abstract

Objectives This study aimed to characterize the clinical utilization of tranexamic acid (TXA) by paramedics in British Columbia (BC) for acute major trauma and to quantify the percentage of patients who received TXA among those who met the indications for administration. Methods A quality assurance review of eligible trauma patients across the province was performed using a convenience sample. Trauma patients between April 1, 2016 and March 31, 2017 with suspected or actual hemorrhage were selected if they met inclusion criteria (systolic blood pressure < 90 mm Hg ± heart rate > 120 beats per minute) and exclusion criteria (age < 16 years, injuries exclusively to the extremities). Results 35 of the 100 eligible patients assessed in this review received a dose of TXA from paramedics. All 35 of the patients received TXA within 180 min of injury regardless of their original location of injury in BC (mean: 50 min; range: 15-140 min). Conclusions 35% of eligible patients identified in this study received TXA, which is an improvement over rates cited by previous Canadian literature. With further education opportunities for paramedics in BC and other EMS systems, there is potential to continue improving pre-hospital TXA administration rates. KeywordsTranexamic acid • Paramedic • Pre-hospital • Trauma • Emergency medicine • Emergency medical service Résumé Objectifs Cette étude visait à caractériser l'utilisation clinique de l'acide tranexamique (TXA) par les ambulanciers paramédicaux de la Colombie-Britannique pour les traumatismes aigus majeurs et à quantifier le pourcentage de patients qui ont reçu du TXA parmi ceux qui répondaient aux indications d'administration. Méthodes Un examen de l'assurance qualité des patients traumatisés admissibles dans toute la province a été effectué à l'aide d'un échantillon de commodité. Les patients traumatisés entre le 1er avril 2016 et le 31 mars 2017 présentant une hémorragie suspectée ou réelle ont été sélectionnés s'ils répondaient aux critères d'inclusion (pression artérielle systolique < 90 mm Hg ± fréquence cardiaque > 120 battements par minute) et aux critères d'exclusion (âge < 16 ans, blessures exclusivement aux extrémités).

Factors that influence the administration of tranexamic acid (TXA) to trauma patients in prehospital settings: a systematic review

“…Patients with a higher Injury Severity Score (ISS) were more likely to receive TXA in both military and civilian settings 17 24 29. This was also the case within various subcohorts of combat casualties, such as those who had a tourniquet applied or with gunshot wounds 29.…”

“…One study was rated ‘strong’20 due to its case–control design. One abstract23 was rated ‘weak’ due to a lack of published information and four other papers were rated ‘weak’ as a result of study design and data collection methods 17–19 24. The qualitative study was rated as ‘valuable’ using the CASP Qualitative Research Checklist 14.…”

“…This factor was the most prevalent (14/19 papers)9 17–19 22–24 26–32 and could be further divided into injury severity, injury site and mechanism of injury.…”

“…This factor encompassed both the contents of protocols (indications for use, route of administration) and how they were used (compliance, confusion) and it was closely linked to injury type. Where described, the details of TXA protocols varied, but usually included exact indications (patient observation ranges and/or mechanism of injury) 18–21 24 25 33–35. Recognised signs of clinical shock were most often the basis of these protocols 18–21 34.…”

“…El-Menyar et al reported that TXA could only be administered by critical care paramedics, and suggested that a lack of availability of these staff led to some eligible patients not receiving TXA 20. Marsden et al found that patients who were given TXA were more likely to be treated by a physician-led crew (60.5% vs 31.6%, p<0.001)9 and Wong et al found that patients receiving TXA were attended by a paramedic of higher certification level than those who did not receive TXA 24. However, some participants in the Goodwin et al study reported that HEMS attendance was a barrier to TXA administration as they preferred to wait for a HEMS team member to administer it 22…”