CRASH-2 Tranexamic Acid in Trauma

November 11, 2017

 

On the Shoulders of Giants

Spoon Feed
Tranexamic acid (TXA) decreased mortality from bleeding in trauma patients.  But there are a few caveats to note.

Why does this matter?
If a pharmacologic agent could be given that would reduce trauma mortality, this would make a dramatic impact when multiplied over the millions of victims each year.  TXA is known to decrease bleeding in surgical patients.  How would it fare in trauma?

CRASH-2
This was a very large RCT with 20,211 patients with blunt and penetrating trauma.  They found a reduction in all cause mortality and mortality from bleeding that was significant, NNT = 67.  Earlier administration appeared to be the most effective.  In fact, a subsequent subgroup analysis found TXA was harmful if given after 3 hours.  There were no adverse effects, such as excessive clotting.  The issue many raised was that TXA had no impact on blood transfusion.  If it assists with clotting, yet patients were still transfused at the same rate, how exactly is TXA working?  The authors state, “One weakness of this trial is that it provides limited insight into how tranexamic acid reduces the risk of death in bleeding trauma patients.”

Source
Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial.  Lancet. 2010 Jul 3;376(9734):23-32. doi: 10.1016/S0140-6736(10)60835-5. Epub 2010 Jun 14.

Another Spoonful

• Don’t miss the LITFL concise summary of CRASH-2 and subsequent TXA studies.
• And this podcast with one of the lead authors, Dr. Coats, on EMCrit.