title: Tranexamic acid administration to pediatric trauma patients in a combat setting: the pediatric trauma and tranexamic acid study (PED-TRAX).
abstract: BACKGROUND
  Early administration of tranexamic acid (TXA) has been associated with a reduction in mortality and blood product requirements in severely injured adults. It has also shown significantly reduced blood loss and transfusion requirements in major elective pediatric surgery, but no published data have examined the use of TXA in pediatric trauma.
  
  
  METHODS
  This is a retrospective review of all pediatric trauma admissions to the North Atlantic Treaty Organization Role 3 hospital, Camp Bastion, Afghanistan, from 2008 to 2012. Univariate and logistic regression analyses of all patients and select subgroups were performed to identify factors associated with TXA use and mortality. Standard adult dosing of TXA was used in all patients.
  
  
  RESULTS
  There were 766 injured patients 18 years or younger (mean [SD] age, 11 [5] years; 88% male; 73% penetrating injury; mean [SD], Injury Severity Score [ISS], 10 [9]; mean [SD] Glasgow Coma Scale [GCS] score, 12 [4]). Of these patients, 35% required transfusion in the first 24 hours, 10% received massive transfusion, and 76% required surgery. Overall mortality was 9%. Of the 766 patients, 66 (9%) received TXA. The only independent predictors of TXA use were severe abdominal or extremity injury (Abbreviated Injury Scale [AIS] score ≥ 3) and a base deficit of greater than 5 (all p < 0.05). Patients who received TXA had greater injury severity, hypotension, acidosis, and coagulopathy versus the patients in the no-TXA group. After correction for demographics, injury type and severity, vitals, and laboratory parameters, TXA use was independently associated with decreased mortality among all patients (odds ratio, 0.3; p = 0.03) and showed similar trends for subgroups of severely injured (ISS > 15) and transfused patients. There was no significant difference in thromboembolic complications or other cardiovascular events. Propensity analysis confirmed the TXA-associated survival advantage and suggested significant improvements in discharge neurologic status as well as decreased ventilator dependence.
  
  
  CONCLUSIONS
  TXA was used in approximately 10% of pediatric combat trauma patients, typically in the setting of severe abdominal or extremity trauma and metabolic acidosis. TXA administration was independently associated with decreased mortality. There were no adverse safety- or medication-related complications identified.
  
  
  METHODS
  Therapeutic study, level IV.
authors.affiliation: From the Department of Surgery, Madigan Army Medical Center, (M.J.E., D.W.N., M.J.M.), Tacoma Washington; Trauma and Acute Care Surgery Service, Legacy Emanuel Medical Center, (S.I., M.J.M.), Portland, Oregon; and Department of Surgery, William Beaumont Army Medical Center, (T.M.W.), El Paso; and US Army Institute of Surgical Research, (S.D.T.), San Antonio, Texas.
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Eckert
authors.forename: Thomas M
authors.initials: TM
authors.lastname: Wertin
authors.forename: Stuart D
authors.initials: SD
authors.lastname: Tyner
authors.forename: Daniel W
authors.initials: DW
authors.lastname: Nelson
authors.forename: Seth
authors.initials: S
authors.lastname: Izenberg
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Martin
mesh_terms: D055826:Afghan Campaign 2001-; D000933:Antifibrinolytic Agents / Q000627:therapeutic use*; D001803:Blood Transfusion; D002648:Child; D005260:Female; D015600:Glasgow Coma Scale; D006801:Humans; D015601:Injury Severity Score; D008297:Male; D012189:Retrospective Studies; D014148:Tranexamic Acid / Q000627:therapeutic use*; D016896:Treatment Outcome; D014947:Wounds and Injuries / Q000097:blood / Q000188:drug therapy* / Q000401:mortality; D014950:Wounds, Penetrating / Q000097:blood / Q000188:drug therapy / Q000401:mortality
chemical_list: D000933:Antifibrinolytic Agents; D014148:Tranexamic Acid