Prehospital administration of tranexamic acid in trauma patients.
In this retrospective study, Wafaisade et al. investigated the effect of prehospital administration of tranexamic acid (TXA) on outcome in civilian trauma patients.
The authors linked the prehospital database of the General German Automobile Club Air Rescue Service and the TraumaRegister of the German Trauma Society in order to identify patients documented in both databases during the period 2012-2014. Using propensity score-based matching, primarily admitted trauma patients who received TXA in the prehospital phase were matched with patients who did not receive prehospital TXA. Two identical cohorts comprising 258 patients in each group, mainly suffering from blunt trauma (~90%) and with a mean ISS of ~24, were identified.
The main finding was that the TXA cohort had a lower early (6-hour, 12-hour and 24-hour) mortality. Mortality at 24 hours was 5.8% in the TXA group compared with 12.4% in the control group (P = 0.01). Although overall hospital mortality was similar in both groups (14.7% vs. 16.3%; P = 0.72), subgroup analyses indicated that the most pronounced mortality differences were observed in patients with a high propensity score, reflecting more severe injuries. Furthermore, the TXA cohort had a longer mean time to death compared to the control cohort (8.8 vs. 3.6 days; P = 0.001).
As with all retrospective studies, there is a significant risk of bias, which is discussed by the authors along with the limitations associated with propensity score-based matching. Furthermore, the authors note that the TXA cohort may have experienced a more complicated course reflected by their longer ICU and hospital stays. This issue is extremely important due to the current debate on the risk-benefit profile of TXA administration in trauma.
Despite these limitations, the authors conclude that this study is the largest civilian study investigating the effect of prehospital TXA administration in trauma patients and that until further evidence emerges the results support the use of TXA during prehospital treatment of severely injured patients.
This conclusion is in agreement with recent European guidelines advocating the use of TXA (1 g loading dose) as early as possible in severely injured patients who are bleeding or at risk of significant haemorrhage, until the results of ongoing RCTs investigating the effect of TXA in trauma are available.
– Sisse Rye Ostrowski
