From the Guidelines
Prehospital TXA may reduce the risk of dying within 24 hours after the injury. This is the correct statement regarding the probable impact of prehospital initiation of tranexamic acid in this severely injured motorcycle crash victim. The patient's high COAST score of 5 indicates significant risk for traumatic coagulopathy, making him an appropriate candidate for TXA, as supported by the European guideline on management of major bleeding and coagulopathy following trauma: sixth edition 1.
Key Points
- The standard dosing for TXA in trauma is 1 gram IV over 10 minutes, followed by 1 gram infused over 8 hours, as recommended by the European guideline 1.
- Early administration (within 3 hours of injury) is crucial for maximizing benefit, as demonstrated by the CRASH-2 trial 1.
- TXA works by inhibiting fibrinolysis and stabilizing clot formation, but it does not reduce the risk of DVT, PE, or ischemic stroke - in fact, there are theoretical concerns about potential increases in thrombotic events, though this was not significantly demonstrated in the trial.
- The PATCH-Trauma trial demonstrated that while TXA did not significantly improve overall 6-month functional outcomes, it did show a potential benefit in reducing early mortality within the first 24 hours post-injury, particularly in patients with severe trauma and signs of hemorrhagic shock like LR.
Administration Considerations
- The administration of TXA should not await results from a viscoelastic assessment, as recommended by the European guideline 1.
- Protocols for the management of bleeding patients should consider administration of the first dose of TXA en route to the hospital, as suggested by the European guideline 1.
Conclusion Not Provided as per Guidelines
Please refer to the provided evidence and guidelines for further information on the management of bleeding and coagulopathy following major trauma.
From the Research
Prehospital Tranexamic Acid (TXA) Administration
- The administration of prehospital TXA has been studied in various trials to determine its effectiveness in reducing mortality and improving outcomes in trauma patients 2, 3, 4, 5, 6.
- The evidence suggests that prehospital TXA may reduce the risk of dying within 24 hours after the injury, with a significant reduction in 24-hour mortality observed in several studies 3, 4, 5.
- However, the evidence on the impact of prehospital TXA on long-term outcomes, such as survival with a favorable functional outcome 6 months after the injury, is limited 2, 6.
- Additionally, the evidence on the effect of prehospital TXA on the risk of deep vein thrombosis (DVT) or pulmonary embolism (PE) within 28 days after the injury is inconsistent, with some studies suggesting no significant difference in the risk of venous thromboembolism 4, 5.
- The evidence also suggests that prehospital TXA may not reduce the risk of ischemic stroke within 24 hours after the injury, as this outcome was not specifically studied in the available trials 2, 3, 4, 5, 6.
Clinical Outcomes
- The available evidence suggests that prehospital TXA may be associated with a reduction in 24-hour mortality, with an odds ratio (OR) of 0.60 (95% confidence interval [CI], 0.37-0.99) observed in one meta-analysis 4.
- Another study found that early prehospital TXA administration was associated with a 65% lower independent hazard for 30-day mortality (hazard ratio [HR] 0.35,95% CI 0.19-0.65, P = 0.001) 3.
- However, the evidence on the impact of prehospital TXA on other clinical outcomes, such as multiple organ failure and transfusion requirements, is limited and inconsistent 3, 5.