Written by Clay Smith
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TXA given in the prehospital setting for isolated traumatic brain injury (TBI) was associated with increased 30-day mortality.
Why does this matter?
CRASH-2 showed lower mortality from bleeding in trauma patients. CRASH-3 showed a slight 28-day mortality benefit in TBI patients with a GCS ≥9, especially in the subgroup to whom TXA was given early. But a recent RCT showed no benefit when TXA was given early, in the prehospital setting, for patients with moderate to severe TBI. This study noted the RCT just mentioned included patients with both moderate and severe injury as well as extracranial injuries. So they are laser focused in this analysis on the impact of TXA on patients with severe TBI and isolated TBI.
TXA by EMS? No.
This was a retrospective look at prospectively collected data from BRAIN-PROTECT. This was a cohort of patients with severe TBI (GCS ≤8) who received prehospital treatment and were flown by helicopter to level 1 Dutch trauma centers. During the ~5-year period of the study, a variety of prehospital treatments were performed, which allowed them to compare cohorts while adjusting for confounders. In all, they included 1,827 patients; 1,375 had confirmed TBI; 719 had isolated TBI. Out of the entire cohort, 693 received TXA; TXA patients tended to be older and more severely injured. Unadjusted analysis showed increased 30-day mortality in the TXA group. However, with multiple logistic regression to adjust for confounders, there was no significant difference in 30-day mortality in the entire cohort or those with confirmed TBI. But in those with isolated TBI, they found a strong association with higher mortality (aOR 4.49, 95%CI 1.57-12.87). The figure shows it best. There is a balance between stopping bleeding and hypercoagulability. It looks like early, prehospital TXA for isolated TBI is probably not safe.
Source
Association Between Prehospital Tranexamic Acid Administration and Outcomes of Severe Traumatic Brain Injury. JAMA Neurol. 2020 Dec 7. doi: 10.1001/jamaneurol.2020.4596. Epub ahead of print.
I don’t think that we can really say that TXA increases mortality in isolated TBI, especially with crash 3s results. This is a retrospective cohort study with about 700 patients who got TXA, vs a placebo controlled RCT of thousands of patients. Say what you want about decreases in mortality in crash 3, but there was certainly no increase in mortality detected.