Tranexamic acid for trauma: Filling the ‘GAP’ in evidence

Abstract

Following findings of the Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage (CRASH-2) trial, tranexamic acid (TxA) use post trauma is becoming widespread. However, issues of generalisability, applicability and predictability beyond the context of study sites remain unresolved. Internal and external validity of the CRASH-2 trial are currently lacking and therefore incorporation of TxA into routine trauma resuscitation guidelines appears premature. The Pre-hospital Antifibrinolytics for Traumatic Coagulopathy and Haemorrhage (PATCH)-Trauma study is a National Health and Medical Research Council-funded randomised controlled trial of early administration of TxA in severely injured patients likely to have acute traumatic coagulopathy. The study population chosen has high mortality and morbidity and is potentially most likely to benefit from TxA's known mechanisms of action. This and further trials involving appropriate sample populations are required before evidence based guidelines on TxA use during trauma resuscitation can be developed.

Use of Tranexamic Acid in Trauma Patients: An Analysis of Cost-Effectiveness for Use in Brazil

“…As occurred with the use of aprotinin, a drug structurally similar to TXA, increased risk of thromboembolic events may appear in later studies 13 . The results of the MATTERs study showed increased occurrence of these events for patients receiving TXA vs. controls: 0.3% of pulmonary thromboembolism in the control group vs. 2.7% (p=0.01) in TXA group, and 0.2% of deep venous thrombosis in the TXA group vs. 2.4% (p=0.01) in controls for deep venous thrombosis 15 .…”

Prehospital transfusion of red cell concentrates in a paramedic‐staffed helicopter emergency medical service

“…There are promising reports of military and civilian experiences in which the feasibility and potential benefits of such protocols are shown . However, ideal practice and the optimal ratio of components for prehospital administration are yet to be established …”

“…The inclusion of thawed plasma, platelets, cryoprecipitate, coagulation factor concentrates and antifibrinolytic drugs into transfusion protocols is a highly debated topic. 19,20 There are promising reports of military and civilian experiences in which the feasibility and potential benefits of such protocols are shown. 2,8,21 However, ideal practice and the optimal ratio of components for prehospital administration are yet to be established.…”

Advances in the understanding of trauma-induced coagulopathy

“…The "shutdown" phenomenon has also added a new dimension of controversy regarding TXA use: whereas some believe it should be reserved for patients who demonstrate hyperfibrinolysis on viscoelastic assays and avoided in those with shutdown, 73 others argue that early TXA use could potentially benefit any patient at risk for hemorrhage. 74 We agree that randomized control trials [75][76][77] to definitively analyze its risks, benefits, and mechanisms of action in mature trauma systems are worthwhile.…”