Written by Rebecca White
Prehospital administration of tranexamic acid (TXA) did not result in greater functional survival in patients with major trauma and suspected trauma-induced coagulopathy.
Is Earlier Better?
Trauma is the leading cause of death in young people, and TXA has previously shown benefit when given in the hospital in 28-day mortality for patients with suspected bleeding (CRASH-2) and in mild-to-moderate traumatic brain injury (CRASH-3).
This double-blind, randomized controlled trial included 1,310 patients with major trauma and suspected trauma-induced coagulopathy, treated within 15 emergency medical services (EMS) systems and then advanced trauma centers in Australia, New Zealand, and Germany from July 2014 to September 2021.
Of these, 661 were randomly assigned to receive TXA, 646 to placebo. TXA dosing was a 1g bolus prehospital followed by a 1g infusion in the hospital within 8-hours. Survival with favorable functional outcome at 6 months occurred in 53.7% of the TXA group (307/572) and 53.5% of the placebo group (299/559; risk ratio 1.00 (95%CI 0.90-1.12; P = 0.95). At 28 days after trauma, 17.3% of the TXA group and 21.8% of the placebo group had died: risk ratio 0.79 (95%CI 0.63-0.99). There was no significant difference in deaths at 6 months or the number of adverse events, including vascular occlusive events, between groups.
Although 13% of patients were excluded due to missing data or administration errors, this is a very well-executed study that is generalizable to the severe trauma population.
How will this change my practice?
TXA has its role in trauma patients; however, we likely won’t be adding TXA to the plate of pre-hospital EMS providers with these results.
Prehospital Tranexamic Acid for Severe Trauma. N Engl J Med. 2023 Jun 14. doi: 10.1056/NEJMoa2215457. Epub ahead of print.