The Use of Tranexamic Acid in Tactical Combat Casualty Care: TCCC Proposed Change 20-02

Drew, Brendon; Auten, Jonathan D.; Andrew, Penny; Deaton, Travis G; Donham, Benjamin; Dorlac, Warren C.; DuBose, Joseph J.; Fisher, Andrew D; Ginn, Alan J.; Hancock, J. F.; Holcomb, John B.; Knight, Jennifer; Koerner, Albert Ken; Littlejohn, Lanny F.; Martin, Matthew J.; Morey, John Kip; Morrison, Jonathan J.; Schreiber, Martin A.; Spinella, Philip C.; Walrath, Benjamin; Butler, Frank K.

doi:10.55460/zwv3-5cbw

Cited by 21 publications

(17 citation statements)

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“…Current US Military prehospital guidelines published by the Committee on Tactical Combat Casualty Care, published in 2020, advocate for the use of a 2-g IV or IO bolus dosing. 31 Previous prospective trials using TXA for hemorrhagic shock have studied total doses of 1, 5 2, 4,5,32,33 or 3 g. 5 In these studies, TXA was not associated with increased risk of thromboembolism. Although total doses were similar to those reported in the present study, the timing was different.…”

Section: Resultsmentioning

confidence: 99%

“…The present trial evaluated 2‐ and 4‐g bolus dosing based on the experience of using doses as high as 10‐g intravenous bolus dosing in cardiac surgery, and the use of multiple doses in combat casualties where the mean (±standard deviation) dose of TXA was 2.3 ± 1.3 g (35–37). Current US Military prehospital guidelines published by the Committee on Tactical Combat Casualty Care, published in 2020, advocate for the use of a 2‐g IV or IO bolus dosing 31 . Previous prospective trials using TXA for hemorrhagic shock have studied total doses of 1, 5 2, 4,5,32,33 or 3 g 5 .…”

Section: Discussionmentioning

confidence: 99%

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The risk of thromboembolic events with early intravenous 2‐ and 4‐g bolus dosing of tranexamic acid compared to placebo in patients with severe traumatic bleeding: A secondary analysis of a randomized, double‐blind, placebo‐controlled, single‐center trial

et al. 2022

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Background Screening for the risk of thromboembolism (TE) due to tranexamic acid (TXA) in patients with severe traumatic injury has not been performed in randomized clinical trials. Our objective was to determine if TXA dose was independently‐associated with thromboembolism. Study Design and Methods This is a secondary analysis of a single‐center, double‐blinded, randomized controlled trial comparing placebo to a 2‐g or 4‐g intravenous TXA bolus dose in trauma patients with severe injury. We used multivariable discrete‐time Cox regression models to identify associations with risk for thromboembolic events within 30 days post‐enrollment. Event curves were created using discrete‐time Cox regression. Results There were 50 patients in the placebo group, 49 in the 2‐g, and 50 in the 4‐g TXA group. In adjusted analyses for thromboembolism, a 2‐g dose of TXA had an hazard ratio (HR, 95% confidence interval [CI]) of 3.20 (1.12–9.11) (p = .029), and a 4‐g dose of TXA had an HR (95% CI) of 5.33 (1.94–14.63) (p = .001). Event curves demonstrated a higher probability of thromboembolism for both doses of TXA compared to placebo. Other parameters independently associated with thromboembolism include time from injury to TXA administration, body mass index, and total blood products transfused. Discussion In patients with severe traumatic injury, there was a dose‐dependent increase in the risk of at least one thromboembolic event with TXA. TXA should not be withheld, but thromboembolism screening should be considered for patients receiving a dose of at least 2‐g TXA intravenously for traumatic hemorrhage.

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Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

The risk of thromboembolic events with early intravenous 2‐ and 4‐g bolus dosing of tranexamic acid compared to placebo in patients with severe traumatic bleeding: A secondary analysis of a randomized, double‐blind, placebo‐controlled, single‐center trial

et al. 2022

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“…In their recent study, Guyette et al 21 found a reduction in the mortality rate in the group of patients who received TXA in the first hour following trauma but also in patients who received 2 g of intravenous TXA over 10 min compared with those who received only 1 g. The latest military recommendations, both in the USA in 202022 and France in 2021,5 already recommend the administration of 2 g of TXA to the war-wounded soldier with a possibly active haemorrhage. The administration of TXA at this dosage does not seem to present any particular adverse effects at the time of administration23 24 and could be considered in the civilian environment soon. Finally, we were able to demonstrate that the low rate of underuse was systematically in severely injured patients.…”

Section: Discussionmentioning

confidence: 99%

Retrospective analysis of tranexamic acid administration in French war-wounded between October 2016 and September 2020

Pinna

Aigle

et al. 2023

BMJ Mil Health

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IntroductionSince 2013, the French Army Health Service, in agreement with international experts, has recommended the administration of 1 g of tranexamic acid (TXA) in trauma patients in haemorrhagic shock or at risk of bleeding within 3 hours of the trauma.MethodsThe aim of this analysis was to describe the administration of TXA in French military personnel wounded during military operations in the Sahelo-Sahelian band between October 2016 and September 2020. Data were collected from forward health records and hospital data from the French hospital where the casualty was finally evacuated. Underuse of TXA was defined as the lack of administration in casualties who had received a blood transfusion with one or more of red blood cells, low-titre whole blood or French lyophilised plasma within the first 24 hours of injury and overuse as its administration in the non-transfused casualty.ResultsOf the 76 patients included, 75 were men with an average age of 28 years. Five patients died during their management. 19 patients received TXA (25%) and 16 patients were transfused (21%). Underuse of TXA occurred in 3 of the 16 patients (18.8%) transfused. Overuse occurred in 6 of 60 (10%) non-transfused patients.ConclusionThe analysis found an important underuse of TXA (almost 20%) and highlighted the need for optimising the prehospital clinical practice guidelines to aid prehospital medical practitioners more accurately in administering TXA to casualties that will require blood products.

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“…The indications for the use of TXA have remained relatively unchanged over the last decade, and it is currently indicated for any penetrating torso or junctional injury as well as in trauma patients with signs of profound shock (Figure 3). 26 In contrast to the current Tactical Combat Casualty Care Guidelines (TCCC), 27 traumatic brain injury is not currently a criterion for TXA administration, and our dosage recommendations have remained at 1 g intravenously in the prehospital setting. During the initial rollout of TXA in the IDF, at least 30% of cases in which it was administered had no clear indication per protocol 23 .…”

Section: Adjuncts For Hemorrhage Controlmentioning

confidence: 99%

Adopting a culture of remote damage control resuscitation in the military: Insights from the Israel defense forces decade of experience

et al. 2023

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Background Remote damage control resuscitation (RDCR) aims to apply the principles of damage control resuscitation to prehospital and austere care, emphasizing early control of compressible hemorrhage, balanced volume resuscitation, and the prevention or correction of coagulopathy, acidosis, hypothermia, and hypocalcemia. Over the past decades, the Israel Defense Forces Medical Corps (IDF‐MC) has made significant efforts to integrate the principles of RDCR into prehospital trauma care in the military. Study Design and Methods In this article, we reflect on the implementation of RDCR in the prehospital setting by the IDF‐MC, sharing successes, challenges, considerations on guideline changes, and their assessment over time. Results The implementation of RDCR has resulted in changes in clinical practice guidelines and training programs, with increased awareness and adoption of RDCR principles among both medical and non‐medical military personnel. The implementation of these principles and adherence to guideline changes have been analyzed using the Israel Defense Forces Trauma Registry. Discussion By sharing our experiences, we hope to provide valuable insights for other military and civilian organizations seeking to adopt similar protocols for prehospital care. Continuous evaluation and refinement of guidelines and training programs will be essential for ongoing implementation and advancement of RDCR in the prehospital setting.

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The Use of Tranexamic Acid in Tactical Combat Casualty Care: TCCC Proposed Change 20-02

Cited by 21 publications

References 0 publications

The risk of thromboembolic events with early intravenous 2‐ and 4‐g bolus dosing of tranexamic acid compared to placebo in patients with severe traumatic bleeding: A secondary analysis of a randomized, double‐blind, placebo‐controlled, single‐center trial

The risk of thromboembolic events with early intravenous 2‐ and 4‐g bolus dosing of tranexamic acid compared to placebo in patients with severe traumatic bleeding: A secondary analysis of a randomized, double‐blind, placebo‐controlled, single‐center trial

Retrospective analysis of tranexamic acid administration in French war-wounded between October 2016 and September 2020

Adopting a culture of remote damage control resuscitation in the military: Insights from the Israel defense forces decade of experience

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