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TRAUMA CARE 2010, showed that TXA, w h e n a d m i n i s t e r e d within one hour of sig- nificant trauma, greatly reduced patient mortal- ity (over 30%) when used i n conju nc t ion w it h blood transfusions. 2,19–21 When TXA was used alone, patient mortal- ity was reduced by over 20%. 1,2,11,19–21 MATTERs was a ret- rospective observational study of 893 consecutive admissions of combat- injured persons in a role 3 surgical hospital (equivalent to a U.S. level 2 trauma center) in southern Afghanistan. In MAT- TERs 293 patients received TXA, while 603 did not. Authors measured patient mortality at 24 hours, 48 hours and 30 days, as well as the influence of TXA administration on postoperative coagulopathy and the rate of thromboembolic complications. 6,7,11,20 The results of both the CRASH-2 and MATTERs studies showed a decrease in the unadjusted mortality of patients who received TXA (vs. placebo) within the first three hours of injury (17.4% vs. 23.9%). 1,5–7,9,15,20,21 Patients who received TXA (vs. placebo) with asso- ciated blood transfusion within one hour of injury had an even greater decrease in mortality (14.4% vs. 28.1%). 1,5–7,9,15,20–22 Both CRASH-2 and MATTERs showed that when TXA was used in conjunction with blood transfusions, mortality decreased further. 1–3,6,18 Overall, the MATTERs findings suggest that TXA is more beneficial in higher-severity traumatic injuries and is more effective when used with massive transfusion protocols covering, for example, blood transfusion, FFP, platelets and cryoprecipitate. By developing local protocols and adding TXA to the paramedic formulary, the national trauma system as a whole could decrease the delay in the administration of TXA, resulting in more trauma patients meeting the three-hour window, but more so the optimal one-hour window from initial trau- ma. TXA administered more than three hours after injury, however, appears to increase the risk of death due to bleeding, to 4.4% compared with 3.1% for the placebo group. The researchers found no evidence that TXA's effect on death due to bleeding varied on the basis of systolic pressure, Glasgow coma score or type of injury. 25 The risk of death in the first year after trauma in the intervention group was calculated by multiplying the baseline cumulative hazard of the placebo group by the relative risk reduction of all-cause mortality as estimated in the CRASH-2 trial. 12 Beyond 12 months the risk of death in the intervention arm was assumed to be equal to that estimated for the placebo arm. 12 Since the CRASH-2 trial only recorded data up to 28 days or death, a parametric survival function was fitted to extrapolate mortality experience over the 12 months following injury. 12 Using this model, research needs to be done in the United States to validate the increased (and standard) use of TXA in patients with or at risk of significant hemorrhage from trauma. 12 The minor side effects recorded with the adminis- tration of TXA include giddiness, allergic dermatitis and gastrointestinal disturbances (nausea, vomiting, diarrhea). The most significant adverse reaction noted in the CRASH-2 trail was hypotension, observed only when the intravenous injection was too rapid, administered in under the 10-minute recommended time. 2,5,7,9,14,15 The above data (in conjunction with the only contraindication to use being suspected sub- arachnoid hemorrhage) suggests the use of TXA is not only more cost-effective, but also more ethical when compared to not using TXA for appropriate patients. 1–4,6,8,12 Conclusion TXA as a standard of care would not be a cost burden. Research has shown that when used in Tanzania, India and the United Kingdom, TXA was cost-effec- tive in reducing the risk of death in bleeding trauma patients. 6,19 When used (compared to not being used), the cost per life-year saved in Tanzania, India and the U.K. was $48, $66 and $64 respectively. 6,19 Life-years gained were estimated from a simple Markov model (i.e., patients were either alive or dead) by comparing the life-years experienced by a cohort given TXA with the cohort that did not receive TXA. 6,19 The cumula- tive risk of death during the first year in the placebo arm was estimated using data from the CRASH-2 study. After the first year patients were assumed to experience the same probability of death as the general population of a similar age, using country- specific life tables from WHO. 2,6,19 TXA is inexpensive, has minimal side effects, has a long shelf life and is easily administered via intra- venous infusion. TXA's efficacy, cost, ease of storage and practicality make it an obvious candidate for addition to the paramedic formulary as a standard of care for trauma patients who have or are at risk of significant hemorrhage. 1–3,6,13,16,18,20 ABOUT THE AUTHOR Jon E. Thomas, BS, ATP, NREMT-P, has been in EMS since his honorable discharge from the U.S. Army in 1991. He has been a civilian instructor for the Special Operations Combat Medic Course at the Joint Special Operations Training Center in Fort Bragg, NC, since August 2004. 26 MARCH 2015 | EMSWORLD.com THE WORLD OF EMS: TXA Host Chris Cebollero chats with New Hanover's Medical Director Heston Lamar and Clinical Education Coordinator Kevin Collopy about the agency's new protocol for the administration of TXA. See EMSWorld.com/12033683.