From the Guidelines
The 49-year-old man with a Glasgow Coma Scale (GCS) score of 11 and bilateral reactive pupils in whom tranexamic acid therapy was initiated within 1 hour after injury is most likely to benefit from tranexamic acid in reducing the risk of head injury-related death. According to the findings from the CRASH-3 study, early treatment with tranexamic acid (TXA) was shown to reduce death in mild and moderate head injury, but not in severe head injury 1. The study demonstrated that TXA was highly cost-effective for mild and moderate head injury and in patients in which both pupils reacted 1. The presence of reactive pupils indicates preserved brainstem function, suggesting the injury may be more salvageable. Patients with unreactive pupils typically have more severe brain damage, and those with very low GCS scores (particularly below 8) generally showed less benefit from tranexamic acid in the study. Some key points to consider in this context include:
- The importance of early administration of TXA, with the CRASH-3 study showing that treatment within 3 hours, but particularly within the first hour after injury, is crucial for reducing the risk of head injury-related death 1.
- The effectiveness of TXA in patients with mild to moderate head injuries, as evidenced by the study's findings that participants with milder head injury may have benefited more from TXA because of a smaller baseline bleed volume 1.
- The potential benefits of TXA in reducing intracranial bleeding and subsequent secondary brain injury, which is critical for improving outcomes in patients with traumatic brain injury. Overall, the evidence suggests that the 49-year-old man with a GCS score of 11 and bilateral reactive pupils is the most likely to benefit from tranexamic acid in reducing the risk of head injury-related death, given the findings of the CRASH-3 study and the importance of early treatment and mild to moderate head injury 1.
From the Research
Patient Selection for Tranexamic Acid Therapy
The CRASH-3 study investigated the effects of tranexamic acid on death, disability, vascular occlusive events, and other morbidities in patients with acute traumatic brain injury 2. Based on the findings, tranexamic acid is most likely to reduce the risk for head injury-related death in patients with the following characteristics:
- Mild to moderate head injury
- Reactive pupils
- Treatment initiated within 3 hours of injury
Comparison of Patient Profiles
Comparing the provided patient profiles:
- A 75-year-old woman with a Glasgow Coma Scale (GCS) score of 8 and bilateral reactive pupils in whom tranexamic acid therapy was initiated within 2 hours after injury
- A 36-year-old man with a Glasgow Coma Scale (GCS) score of 9 and bilateral unreactive pupils in whom tranexamic acid therapy was initiated within 2 hours after injury
- A 51-year-old woman with a Glasgow Coma Scale (GCS) score of 4 and bilateral unreactive pupils in whom tranexamic acid therapy was initiated within 1 hour after injury
- A 49-year-old man with a Glasgow Coma Scale (GCS) score of 11 and bilateral reactive pupils in whom tranexamic acid therapy was initiated within 1 hour after injury
The patient who is most likely to benefit from tranexamic acid therapy is the 49-year-old man with a GCS score of 11 and bilateral reactive pupils, as he has a mild to moderate head injury and reactive pupils, and treatment was initiated within 1 hour of injury 3, 4.
Key Findings from the CRASH-3 Study
The CRASH-3 study found that:
- Tranexamic acid reduces head injury-related death in patients with mild to moderate head injury (RR 0.78 [95% CI 0.64-0.95]) 2
- Early treatment is more effective than late treatment in patients with mild and moderate head injury (p=0.005) 2
- The risk of head injury-related death is reduced with tranexamic acid in patients with reactive pupils and/or mild to moderate GCS at baseline 3, 4