Is it time for tranexamic acid in the pre-hospital setting?

Recently, we had an elderly patient brought into the ED after being involved in a fairly substantial motor vehicle collision. As we began treating her, I asked the trauma surgeon who was taking over the patient’s care whether he wanted tranexamic acid given (TXA). As she was relatively hemodynamically stable (despite several  transient hypotensive episodes), he declined providing her with TXA without elaborating.

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In my view, this patient was definitely someone who would have benefited from TXA especially after later imaging revealed retroperitoneal bleeding. I also wondered, whether this patient could have been given TXA in the pre-hospital setting? At ARHT, we’re not currently using TXA but there’s some question as to whether the pre-hospital setting may be an optimal place for initiation of therapy.

In 2010, the Crash-2 study was published. It was an unbelievably impressive undertaking that randomized trauma patients (a very broad cohort) to TXA or placebo. More than 20,000 patients were enrolled in 40 countries, many of which were resource poor settings. The results were quite remarkable with an absolute risk reduction in all cause mortality from 16% (placebo) to 14.5% (TXA). The authors concluded that “TXA should be considered for use in bleeding trauma patients”.

A closer look at the data suggests that this benefit is primarily if TXA is administered within 3hrs of injury. More recently, additional analysis revealed that death due to bleeding was significantly reduced when administered in <1hr (NNT 42) and between 1-3hrs. This re There was concern about harm if there was a delay >3hrs.

This time dependent effect has considerable ramifications for pre-hospital health care providers. As far as I can tell, there’s no data to support the use of TXA in the prehospital setting but our existing data would support early administration which could easily be provided for patients before arriving in hospital. In particular, patients with prolonged extrications, longer scene times or longer transport times may benefit the most.

A recent retrospective study (MATTERs) study looked at the use of TXA in a combat setting among patients who received at least 1 unit of red cells. They found an association with lower mortality for those who received TXA. Clearly the methodology of the study precludes immediate clinical adoption but it provides additional evidence of the possible benefits.

My bias is that if this was a drug that wasn’t off patent and that there was some pharmaceutical company that could make billions then we would be much more aggressive with its use. In cardiology, most statins have numbers needed to treat of 100-200 and yet with massive (an apparently effective) marketing campaigns, I’ve heard some cardiologists say it should be in the drinking water! I digress.

I think it’s time to consider TXA in the pre-hospital trauma setting in a well defined protocol. The relatively broad inclusion criteria used in Crash-2 which still resulted in impressive outcomes suggests that it would be reasonable to consider in many of our suspected bleeding patients prior arrive in hospital.  And clearly, there needs to be a move within the hospitals and trauma bays to actually implement protocols and give TXA early. Based on existing evidence, we will only be providing better patient care.