Living More Days with TXA?

June 20, 2024

Written by Seth Walsh-Blackmore

Spoon Feed
This bias-adjusted meta-analysis of randomized controlled trials (RCT) finds a one-month mortality benefit in trauma patients receiving tranexamic acid (TXA) during initial emergency management.

Living more days with TXA
Roughly a third of all trauma deaths ultimately occur via exsanguination.^1,2 TXA is an antifibrinolytic that stabilizes existing clots and is practical for administration in the emergency setting.³ This meta-analysis pools seven RCTs comparing TXA to placebo for over 32,000 trauma patients > 15 years old during out-of-hospital or emergency department management for mortality at 1 month (28 or 30-day follow-up).  All trials followed a similar protocol of at least 1g TXA over 10 min followed by an infusion of at least 1g over 8 hours. The MASTER scale assessed methodological quality with an average score of 33 out of a possible 36. Bias adjustment was via a quality-effects model, which has outperformed random-effects models.⁴

The headline result is a pooled odds ratio of 0.89 (95%CI 0.84 – 0.95) for one-month mortality in patients receiving TXA. An absolute risk difference of – 1.7% (95%CI – 0.7% to – 2.4%) for one-month mortality in those receiving TXA was derived from the pooled OR, with a number needed to treat 61. Vascular occlusive event rates were not significantly different between groups (OR 0.96 95%CI 0.73 – 1.27). Heterogeneity was low (I²=0.0%).

How will this change my practice?
It’s hard to ignore high-level evidence with a number needed to treat 61 for mortality in trauma. However, a 28-day mortality benefit did not translate to a 6-month mortality benefit in the PATCH trial or improve functional outcomes in the CRASH-3 trial. A one-month mortality benefit is valuable to family and organ procurement, so given its practicality and strong safety profile, I will continue to administer TXA to trauma patients when indicated.

Another Spoonful
JournalFeed has followed the TXA in trauma evolution via the most significant trials of the last 20 years: CRASH-2 , CRASH-3, and PATCH.

Source
Tranexamic Acid for Traumatic Injury in the Emergency Setting: A Systematic Review and Bias-Adjusted Meta-Analysis of Randomized Controlled Trials. Ann Emerg Med. 2024 May;83(5):435-445. doi: 10.1016/j.annemergmed.2023.10.004. Epub 2023 Nov 22. PMID: 37999653.

Works Cited

1. Evans, Julie A., et al. Epidemiology of traumatic deaths: comprehensive population-based assessment. World journal of surgery 34 (2010): 158-163.
2. Sauaia, Angela, et al. Epidemiology of trauma deaths: a reassessment. Journal of Trauma and Acute Care Surgery 38.2 (1995): 185-193.
3. Cai, Johnny, et al. The many roles of tranexamic acid: an overview of the clinical indications for TXA in medical and surgical patients. European journal of haematology 104.2 (2020): 79-87.
4. Doi SAR, Furuya-Kanamori L. Selecting the best meta-analytic estimator for evidence-based practice: a simulation study. Int J Evid Based Healthc. 2020;18:86-94.