Prehospital Use of Tranexamic Acid for Hemorrhagic Shock in Primary and Secondary Air Medical Evacuation

doi:10.1016/j.amj.2013.05.001

Air Medical Journal

Volume 32, Issue 5, September–October 2013, Pages 289-292

https://doi.org/10.1016/j.amj.2013.05.001 Get rights and content

Abstract

Introduction

Major hemorrhage remains a leading cause of death in both military and civilian trauma. We report the use of tranexamic acid (TXA) as part of a trauma exanguination/massive transfusion protocol in the management of hemorrhagic shock in a civilian primary and secondary air medical evacuation (AME) helicopter EMS program.

Methods

TXA was introduced into our CCP flight paramedic program in June 2011. Indications for use include age > 16 years, major trauma (defined a priori based on mechanism of injury or findings on primary survey), and heart rate (HR) > 110 beats per minute (bpm) or systolic blood pressure (SBP) < 90 mmHg. Our protocol, which includes 24-hour online medical oversight, emphasizes rapid initiation of transport, permissive hypotension in select patients, early use of blood products (secondary AME only), and infusion of TXA while en route to a major trauma center.

Results

Over a 4-month period, our CCP flight crews used TXA a total of 13 times. Patients had an average HR of 111 bpm [95% CI 90.71–131.90], SBP of 91 mmHg [95% CI 64.48–118.60], and Glascow Coma Score of 7 [95% CI 4.65–9.96]. For primary AME, average response time was 33 minutes [95% CI 19.03–47.72], scene time 22 minutes [95% CI 20.23–24.27], and time to TXA administration 32 minutes [95% CI 25.76–38.99] from first patient contact. There were no reported complications with the administration of TXA in any patient.

Conclusion

We report the successful integration of TXA into a primary and secondary AME program in the setting of major trauma with confirmed or suspected hemorrhagic shock. Further studies are needed to assess the effect of such a protocol in this patient population.

Introduction

Massive hemorrhage remains a leading cause of preventable death in both military and civilian realms. Multiple strategies exist to mitigate the morbidity and mortality associated with such trauma, including both medical and technical interventions and the early deployment of surface and air ambulances to rapidly transport patients to advanced medical and surgical aid. Most recently, attention has been refocused on the use of antifibrinolytic agents as one of many medical strategies to mitigate the effects of massive hemorrhage.¹ In the highly pragmatic series, the clinical randomization of an antifibrinolytic in significant hemorrhage-2 (CRASH-2) trial investigators observed a mortality benefit in those patients administered tranexamic acid (TXA) if they had actual or potential indicators of massive hemorrhage based on the mechanism of injury or presenting physiology. There are some methodologic considerations to the CRASH-2 trial one must consider before generalizing to other populations; however, this article was instrumental in thrusting TXA into the spotlight as a cost-effective, lifesaving, medical adjunct in the management of trauma-induced hemorrhagic shock. After the publication of the CRASH-2 trial and a review of the current literature on the use of antifibrinolytics for controlling or minimizing surgical bleeding, our group believed that there was sufficient evidence for the introduction of TXA into the prehospital arena as an adjunct in combating the effects of major blood loss before arrival to definitive care. In this report, we describe the integration of TXA as part of a trauma exsanguination/massive transfusion protocol in the management of hemorrhagic shock in a civilian, primary, and secondary air medical evacuation (AME) helicopter emergency medical services program.

Section snippets

Methods

The British Columbia Ambulance Service's (BCAS) AirEvac and Critical Care Operations provides emergency medical services for the province of British Columbia, covering 944,735 square kilometers (364,800 sq mi) and servicing a population of just under 5 million people (approximately 2.5 million in the Greater Vancouver area). The BCAS AirEvac and Critical Care Operation performs approximately 8,000 missions per year, via both fixed and rotary wing aircraft (KingAir 350, Lear 31A, and Sikorsky

Results

Over a 4-month period, our CCP flight crews used TXA on a total of 13 patients. Patient demographics and mission descriptors are summarized in Table 1. All patients had clinical criteria suggestive of actual or potential massive hemorrhage (Table 2) with a mean Revised Trauma Score of 5.96.⁷

For primary AME (scene response, N 5 8), the average response time (from takeoff to patient side) was 33 minutes (95% confidence interval [CI], 19.03–47.72], the average scene time was 22 minutes (95% CI,

Discussion

In this report, we have described the integration of TXA into a massive hemorrhage/trauma exsanguination protocol as a medical addition to current standard practice. Based on the available evidence for the use of antifibrinolytics and the mechanism of action, these adjuncts are best used early in the clotting process and, thus, best administered in the prehospital setting provided all other basic principles of advanced trauma life support (ATLS) have been addressed.

Recent trauma literature has

Conclusion

In summary, we report the successful integration of TXA into an out-of-hospital primary and secondary air medical evacuation program in the setting of major trauma with confirmed or suspected hemorrhagic shock. We believe our experience with this pharmacologic intervention reflects the most up-to-date pattern of practice for major hemorrhage in trauma. Provided that other basic principles of prehospital care are adhered to, including rapid transport and those principles espoused by ATLS, we

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To Tranexamic Acid or Not to Tranexamic Acid? Accuracy of Antifibrinolytic Administration at Altitude
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Tranexamic acid (TXA) has demonstrated a reduction in all-cause mortality in trauma patients with hemorrhage. Administering TXA in the prehospital setting presents unique challenges because the identification of bleeding is based on clinical suspicion without advanced imaging or diagnostic tools. The objective of this study was to examine whether prehospital suspicion of bleeding is validated by in-hospital computed tomographic imaging and examination and to determine if patients received TXA in the absence of hemorrhage. The study was conducted at a level 1 trauma center supported by air medical transport services.
This is a retrospective cohort study examining 88 trauma patients receiving prehospital TXA to treat suspected hemorrhage. Adult trauma patients who received TXA during the study period and were transported to our level 1 trauma center were included. A panel of trauma surgeons reviewed CT imaging and examination findings to retrospectively identify significant hemorrhage.
Forty-three percent of patients who received TXA during air medical transport did not have confirmed hemorrhage upon arrival.
TXA was given to a significant number of patients who did not have confirmed hemorrhage upon arrival. We recommend that institutions using TXA perform this internal validation to ensure they are accurately identifying hemorrhage in the prehospital setting.
Use of Tranexamic Acid in Traumatic Resuscitation in a Prehospital Setting: A Case Report
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This study describes the use of tranexamic acid associated with other measures in the initial approach to contain bleeding in a situation of hemorrhagic shock in a trauma patient. The case describes the care of a young man with multiple thorax punctures by a melee weapon, quickly progressing to a condition of severe shock, in addition to the action of a helicopter emergency medical team supporting the patient's transportation from a low-complexity emergency care unit to a specialized unit.
Evaluation of tranexamic acid in trauma patients: A retrospective quantitative analysis
2019, American Journal of Emergency Medicine
Tranexamic acid (TXA) has been shown to decrease mortality in adult trauma patients with or at significant risk of hemorrhage when administered within 3 h of injury. The use and appropriateness of TXA in adult trauma patients presenting to Royal Columbian Hospital (RCH) was investigated.
This retrospective chart review utilized the British Columbia Trauma Registry to identify 100 consecutive trauma patients that presented to the emergency department at RCH between April 2012 to June 2015 and met the following indications for TXA: systolic blood pressure <90 mm Hg and/or heart rate >110 bpm and presentation within 8 h of injury. Primary outcomes included: percentage that met indications for TXA, received TXA according to the CRASH-2 protocol, received a pre-hospital dose, and received TXA ≤1, >1 to ≤3, or >3 h from injury.
During the given time period, 117 subjects (2.7%) met indications for TXA. 67 patients (57%) received TXA in any dose, with 10 subjects (8.5%) receiving TXA according to the CRASH-2 protocol. Of the 67 patients who received any TXA, 76% did so ≤3 h. 22 patients (19%) received TXA as a pre-hospital dose.
<10% of adult trauma patients that met the indication for TXA received it according to the CRASH-2 protocol. Of those patients that received TXA, 76% did so within 3 h. Further inquiry to identify reasons trauma patients are not receiving TXA as well as quality improvement initiatives in trauma care are required.
III
Therapeutic
Efficacy of prehospital administration of tranexamic acid in trauma patients: A meta-analysis of the randomized controlled trials
2018, American Journal of Emergency Medicine
Citation Excerpt :
Although the latter 2 outcomes were statistically not significant because of less statistical power, both might still have clinical implications. Although, there is no published randomized clinical trial (RCT) yet, at least 10 published studies have addressed the beneficial effect of prehospital TXA use for the treatment of significant bleeding in trauma patients [8,16-24]. Up to the best of our knowledge, this is the first attempt to conduct a meta-analysis in this regard.
Antifibrinolytic agent tranexamic acid (TXA) has a potential clinical benefit for in-hospital patients with severe bleeding but its effectiveness in pre-hospital settings remains unclear. We conducted a systematic review and meta-analysis to evaluate whether pre-hospital administration of TXA compared to placebo improve patients' outcomes?
PubMed, MEDLINE, Cochrane Library, WHO International Clinical Trials Registry Platform, Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, clinicaltrials.gov and Google scholar databases were searched for a retrospective, prospective and randomized (RCT) or quasi-RCT studies that assessed the effect of prehospital administration of TXA versus placebo on the outcomes of trauma patients with significant hemorrhage. The main outcomes of interest were 24 hour 30-day mortality and in-hospital thromboembolic complications. Two authors independently abstracted the data using a data collection form. Results from different studies were pooled for the analysis, when appropriate.
Out of 92 references identified through the search, two analytical studies met the inclusion criteria. The effect of TXA on 24-hour mortality had a pooled odds ratio (OR) of 0.49 (95% CI 0.28–0.85), 30-day mortality OR of 0.86 (95% CI, 0.56–1.32), and thromboembolic events OR of 0.74 (95% CI, 0.27–2.07).
Prehospital TXA appears to reduce early mortality in trauma patients. The pooled analysis also shows a trend toward lower 30-day mortality and reduced risk of thromboembolic events. Additional randomized controlled clinical trials are needed to determine the significance of these trends.
Logistical Concerns for Prehospital Blood Product Use by Air Medical Services
2017, Air Medical Journal
Over the past few decades, reports have described favorable results from transfusion of blood products in helicopter EMS (HEMS). Nevertheless, the initiation of a HEMS transfusion program requires consideration of many factors, some unique to each clinical site. This paper describes our experience developing a HEMS transfusion program in an urban non-hospital based HEMS program with a history of long transport times. When considering blood use away from the hospital, major consideration must be given to safe storage and monitoring of blood products both on the ground and while in flight. PRBCs have been shown to generally be resilient to helicopter transit and have a prolonged storage duration. Transfusion of other blood products, such as plasma, involves additional challenges but has been achieved by some HEMS sites. Flight protocols should be developed addressing when and how many blood products should be transported, potentially considering patient factors, scene factors, and the regional availability of blood products during interfacility transport. Quality assurance and documentation protocols must also be developed for blood product use in flight. In our center's experience, we have so far transfused a limited number of patients with generally good results. Patient outcomes are described as below.
Future Developments in the Management of Explosive Incidents
2017, Annals of Emergency Medicine

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Original ResearchPrehospital Use of Tranexamic Acid for Hemorrhagic Shock in Primary and Secondary Air Medical Evacuation

Abstract

Introduction

Methods

Results

Conclusion

Introduction

Section snippets

Methods

Results

Discussion

Conclusion

J Thorac Cardiovasc Surg

Ann Thorac Surg

Br J Anaesth

Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomized, placebo-controlled trial

Lancet

The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomised controlled trial

Lancet

Management of bleeding following major trauma: an updated European guideline

Crit Care

A revision of the Trauma Score

J Trauma

Targeted resuscitation improves coagulation and outcome

J Trauma

Acute traumatic coagulopathy

J Trauma

Functional definition and characterization of acute traumatic coagulopathy

Crit Care Med

Acute traumatic coagulopathy

Curr Opin Anaesthesiol

Original Research
Prehospital Use of Tranexamic Acid for Hemorrhagic Shock in Primary and Secondary Air Medical Evacuation