Abstract
BackgroundEarly hemorrhage control is important in trauma-related death prevention. Tranexamic acid (TXA) has shown to be beneficial in patients in hemorrhagic shock, although widespread adoption might result in incorrect TXA administration leading to increased morbidity and mortality.MethodsA 7-year prospective cohort study with consecutive trauma patients admitted to a Level-1 Trauma Center ICU was performed to investigate administration of both pre- and in-hospital TXA and its relation to morbidity and mortality. Indication for prehospital and in-hospital TXA administration was (suspicion of) hemorrhagic shock, and/or systolic blood pressure (SBP) ≤ 90 mmHg. Demographics, data on physiology, resuscitation and outcomes were prospectively collected.ResultsFour hundred and twenty-two patients (71% males, median ISS 29, 95% blunt injuries) were included. Even though TXA patients were more severely injured with more deranged physiology, no differences in outcome were noted. Overall, thrombo-embolic complication rate was 8%. In half the patients, hemorrhagic shock was the indication for prehospital TXA, whereas 79% of in-hospital TXA was given based on suspicion of hemorrhagic shock. Thirteen percent of patients with SBP ≤ 90 mmHg in ED received no TXA at all. Based on SBP alone, 22% of prehospital TXA and 25% of in-hospital TXA were justified.ConclusionsDespite being more severely injured, TXA patients had similar outcome compared to patients without TXA. Thrombo-embolic complication rate was low despite liberal use of both prehospital and in-hospital TXA. Caution should be exercised in selecting patients for TXA, although this might be challenging based on SBP alone in patients who do not yet show signs of deranged physiology on arrival in ED.
Highlights
Hemorrhage control is important in trauma-related death prevention
Even though Tranexamic acid (TXA) patients were more severely injured with more deranged physiology, no differences in outcome were noted
Hemorrhagic shock was the indication for prehospital TXA, whereas 79% of in-hospital TXA was given based on suspicion of hemorrhagic shock
Summary
Hemorrhage control is important in trauma-related death prevention. Tranexamic acid (TXA) has shown to be beneficial in patients in hemorrhagic shock, widespread adoption might result in incorrect TXA administration leading to increased morbidity and mortality. World J Surg (2021) 45:2398–2407 rates of both overall mortality and in hemorrhage-caused mortality as a result of early administration of TXA in adults who sustained an injury within 8 h and had either significant hemorrhage, hypotension or who were considered to be at risk of significant hemorrhage [5] These results have led to widespread incorporation of TXA in damage control resuscitation with low thresholds to administer TXA, including in prehospital settings. Data in the literature have been contradicting, with others reporting no significant differences or even decreased adverse effects [10,11,12,13,14] At present, it remains unclear what the exact mechanism behind TXA is and how it has reduced mortality in CRASH-2 trial, since there was no reduction in packed red blood cells (PRBC) transfusion between patients who received TXA and the ones who did not [5]. Data are still lacking regarding which trauma patients might benefit most, optimal dosing and timing and potential complications in both prehospital and in-hospital setting [4, 15]
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