The pre-hospital administration of tranexamic acid to patients with multiple injuries and its effects on rotational thrombelastometry: a prospective observational study in pre-hospital emergency medicine

Nils Kunze-Szikszay,Christopher Spering,Pauline Wildenauer,Tim Heyne,Markus Roessler,Karoline Walliser,Lennart A Krack,Saskia Wand,Martin Bauer,Michael Quintel

doi:10.1186/s13049-016-0314-4

Abstract

BackgroundHyperfibrinolysis (HF) is a major contributor to coagulopathy and mortality in trauma patients. This study investigated (i) the rate of HF during the pre-hospital management of patients with multiple injuries and (ii) the effects of pre-hospital tranexamic acid (TxA) administration on the coagulation system.MethodsFrom 27 trauma patients with pre-hospital an estimated injury severity score (ISS) ≥16 points blood was obtained at the scene and on admission to the emergency department (ED). All patients received 1 g of TxA after the first blood sample was taken. Rotational thrombelastometry (ROTEM) was performed for both blood samples, and the results were compared. HF was defined as a maximum lysis (ML) >15 % in EXTEM.ResultsThe median (min-max) ISS was 17 points (4–50 points). Four patients (15 %) had HF diagnosed via ROTEM at the scene, and 2 patients (7.5 %) had HF diagnosed via ROTEM on admission to the ED. The median ML before TxA administration was 11 % (3–99 %) vs. 10 % after TxA administration (4–18 %; p > 0.05). TxA was administered 37 min (10–85 min) before ED arrival. The ROTEM results before and after TxA administration did not significantly differ. No adverse drug reactions were observed after TxA administration.DiscussionHF can be present in severely injured patients during pre-hospital care. Antifibrinolytic therapy administered at the scene is a significant time saver. Even in milder trauma fibrinogen can be decreased to critically low levels. Early administration of TxA cannot reverse or entirely stop this decrease.ConclusionsThe pre-hospital use of TxA should be considered for severely injured patients to prevent the worsening of trauma-induced coagulopathy and unnecessarily high fibrinogen consumption.Trial registrationClinicalTrials.gov ID NCT01938768 (Registered 5 September 2013).

Highlights

Hyperfibrinolysis (HF) is a major contributor to coagulopathy and mortality in trauma patients
The extent of fibrinolysis and fibrinogen consumption will increase during pre-hospital treatment and patient transportation, which was demonstrated by Theusinger et al, who did not administer tranexamic acid (TxA) prior to hospital admission, resulting in an HF rate that was 6 % higher upon hospital arrival [11]
Despite the limitations of our small sample size and the heterogeneity of our study population, our results suggest that early antifibrinolytic therapy leads to less fibrinolytic activation, and lower fibrinogen consumption, resulting in an improved function of the coagulation system at hospital admission

Summary

Introduction

Hyperfibrinolysis (HF) is a major contributor to coagulopathy and mortality in trauma patients. Trauma-associated coagulopathy occurs early and is an important contributor to mortality in severely injured patients [3]. As a result of the massive coagulation activation after major trauma, the physiological process of fibrinolysis can exceed fibrin formation, which can induce the breakdown of freshly formed clots. This phenomenon, known as hyperfibrinolysis (HF), impedes the formation of functional clots and can become a major contributor to the consumption of coagulation factors, in particular fibrinogen. The exact point at which fibrinolysis extents fibrin formation and HF begins is unknown

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