Do all trauma patients benefit from tranexamic acid?
BACKGROUND
This study tested the hypothesis that early routine use of tranexamic acid (TXA) reduces mortality in a subset of the most critically injured trauma intensive care unit patients.


METHODS
Consecutive trauma patients (n = 1,217) who required emergency surgery (OR) and/or transfusions from August 2009 to January 2013 were reviewed. At surgeon discretion, TXA was administered at a median of 97 minutes (1-g bolus then 1-g over 8 hours) to 150 patients deemed high risk for hemorrhagic death. With the use of propensity scores based on age, sex, traumatic brain injury (TBI), mechanism of injury, systolic blood pressure, transfusion requirements, and Injury Severity Score (ISS), these patients were matched to 150 non-TXA patients.


RESULTS
The study population was 43 years old, 86% male, 54% penetrating mechanism of injury, 25% TBI, 28 ISS, with 22% mortality. OR was required in 78% at 86 minutes, transfusion was required in 97% at 36 minutes, and 75% received both. For TXA versus no TXA, more packed red blood cells and total fluid were required, and mortality was 27% versus 17% (all p < 0.05). The effects of TXA were similar in those with or without TBI, although ISS, fluid, and mortality were all higher in the TBI group. Mortality associated with TXA was influenced by the timing of administration (p < 0.05), but any benefit was eliminated in those who required more than 2,000-mL packed red blood cells, who presented with systolic blood pressure of less than 120 mm Hg or who required OR (all p < 0.05).


CONCLUSIONS
For the highest injury acuity patients, TXA was associated with increased, rather than reduced, mortality, no matter what time it was administered. This lack of benefit can probably be attributed to the rapid availability of fluids and emergency OR at this trauma center. Prospective studies are needed to further identify conditions that may override the benefits from TXA.


METHODS
Therapeutic study, level IV.
From the Divisions of Trauma and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida.
Evan J
EJ
Valle
Casey J
CJ
Allen
Robert M
RM
Van Haren
Jassin M
JM
Jouria
Hua
H
Li
Alan S
AS
Livingstone
Nicholas
N
Namias
Carl I
CI
Schulman
Kenneth G
KG
Proctor
D000328:Adult; D000933:Antifibrinolytic Agents / Q000008:administration & dosage; D001930:Brain Injuries / Q000150:complications / Q000175:diagnosis / Q000628:therapy*; D004305:Dose-Response Relationship, Drug; D004311:Double-Blind Method; D005260:Female; D005500:Follow-Up Studies; D006439:Hemodynamics; D006801:Humans; D015994:Incidence; D007275:Injections, Intravenous; D015601:Injury Severity Score; D020198:Intracranial Hemorrhage, Traumatic / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control*; D008297:Male; D011379:Prognosis; D011446:Prospective Studies; D012151:Resuscitation / Q000379:methods*; D012307:Risk Factors; D015996:Survival Rate / Q000639:trends; D014148:Tranexamic Acid / Q000008:administration & dosage*; D014193:Trauma Centers; D014481:United States / Q000453:epidemiology
D000933:Antifibrinolytic Agents; D014148:Tranexamic Acid