Tranexamic Acid in Civilian Trauma Care in the California Prehospital Antifibrinolytic Therapy Study

Abstract

IntroductionHemorrhage is one of the leading causes of death in trauma victims. Historically, paramedics have not had access to medications that specifically target the reversal of trauma-induced coagulopathies. The California Prehospital Antifibrinolytic Therapy (Cal-PAT) study seeks to evaluate the safety and efficacy of tranexamic acid (TXA) use in the civilian prehospital setting in cases of traumatic hemorrhagic shock.MethodsThe Cal-PAT study is a multi-centered, prospective, observational cohort study with a retrospective comparison. From March 2015 to July 2017, patients ≥ 18 years-old who sustained blunt or penetrating trauma with signs of hemorrhagic shock identified by first responders in the prehospital setting were considered for TXA treatment. A control group was formed of patients seen in the five years prior to data collection cessation (June 2012 to July 2017) at each receiving center who were not administered TXA. Control group patients were selected through propensity score matching based on gender, age, Injury Severity Scores, and mechanism of injury. The primary outcome assessed was mortality recorded at 24 hours, 48 hours, and 28 days. Additional variables assessed included total blood products transfused, the hospital and intensive care unit length of stay, systolic blood pressure taken prior to TXA administration, Glasgow Coma Score observed prior to TXA administration, and the incidence of known adverse events associated with TXA administration.ResultsWe included 724 patients in the final analysis, with 362 patients in the TXA group and 362 in the control group. Reduced mortality was noted at 28 days in the TXA group in comparison to the control group (3.6% vs. 8.3% for TXA and control, respectively, odds ratio [OR]=0.41 with 95% confidence interval [CI] [0.21 to 0.8]). This mortality difference was greatest in severely injured patients with ISS >15 (6% vs 14.5% for TXA and control, respectively, OR=0.37 with 95% CI [0.17 to 0.8]). Furthermore, a significant reduction in total blood product transfused was observed after TXA administration in the total cohort as well as in severely injured patients. No significant increase in known adverse events following TXA administration were observed.ConclusionFindings from the Cal-PAT study suggest that TXA use in the civilian prehospital setting may safely improve survival outcomes in patients who have sustained traumatic injury with signs of hemorrhagic shock.

An Interesting Civilian Case of Complex Maxillofacial Trauma Due to Target Fragmentation Following Bullet Impact and Review of the Branches of the Maxillary Artery

“…Given the complex maxillofacial regional bony and vascular anatomy relationships, such control techniques are challenging in the trauma setting prior to operative exploration. This case further highlights the potential survival benefits demonstrated in the use of TXA in civilian vascular trauma [18][19].…”

A scoping review of worldwide studies evaluating the effects of prehospital time on trauma outcomes

“…Of 96 articles included, the overwhelming majority (90, 94%) were observational with a few (6, 6%) being interventional in design (Table 2 ) [ 69 , 78 , 85 , 88 , 95 , 98 ]. The six interventional studies evaluated the effects of prehospital blood product transfusion (plasma and packed red blood cells), and TXA administration on mortality, and used time (from injury to intervention) as a covariate.…”

“…Prehospital time was used as an outcome measure in 10 (10%) studies [ 2 , 61 , 62 , 74 , 75 , 83 , 85 , 88 , 94 , 98 ]. Four of these studies evaluated the time resultant from one of the following independent factors: prehospital endotracheal intubation, chest tube insertion, needle thoracostomy, tourniquet application, cricothyroidotomy, and advanced cardiac life support [ 61 , 74 , 75 , 83 ].…”

“…They found that there were associations between prehospital intubation and longer scene times (median 9 vs. 8 min p < 0.001), transport times (median 26 vs. 19 min, p < 0.001), days on a ventilator (mean 7.3 vs. 6.9, p = 0.006), ICU (median 6 vs 5 days, p < 0.001) and hospital length of stay (median 10 vs 9 days, p < 0.001), and higher in-hospital mortality (31.4 vs. 27.5%, p < 0.001) [ 61 ]. Meanwhile, three articles (corresponding to two research studies) investigated the effect on prehospital time due to initiation of prehospital plasma infusion and tranexamic acid (TXA) administration [ 85 , 88 , 89 ]. Lastly, three studies looked at prehospital time, measured as dispatch time to definitive care, as an outcome resultant from different system-based variables, including trauma “deserts” in an urban area [ 2 ], a physician-staffed vs paramedic-staffed regional rotary wing aeromedical (helicopter) EMS system [ 62 ], and indirect vs direct transfer of TBI patients [ 94 ].…”

Safety and Efficacy of Hospital Utilization of Tranexamic Acid in Civilian Adult Trauma Resuscitation

“…While some studies have not identified an increase in incidence of VTE associated with TXA, others have found TXA to be an independent risk factor for increased incidence of VTE. 11,12,14,[17][18][19] Thus, there is a need to continue to further evaluate the safety of TXA use within the hospital trauma setting.…”