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Tranexamic Acid Administration in Patients with Traumatic Injury: A Practice Management Guideline from the Eastern Association for the Surgery of Trauma2020
Type: New Practice Management Guideline (PMG)
Category: Surgical Critical Care
Committee Liaison: Rachel S. Morris, MD, FACS
Team leader(s)
Statement:
Viscoelastic testing has become more prevalent and widely available across trauma systems throughout the United States. This technology has allowed for the characterization of trauma-induced coagulopathy (TIC) phenotypes, specifically hyperfibrinonolysis and fibrinolysis shutdown. Both of these pathologic phenotypes have been associated with increased morbidity and mortality. Over the past decade, critical studies have improved our knowledge about the role of Tranexmic Acid (TXA) in the treatment of TIC. Most recently, the CRASH-2 and 3 trials have added robust, high-quality data to help inform the use of TXA in the hospital setting. Beyond the hospital setting, two large, prehospital TXA randomized controlled trials are now complete and in pre-publication. Two distinct patient populations have been studied: patients at risk for traumatic hemorrhage, and patients with concern for traumatic brain injury. Additionally, several smaller but well-conducted studies such as the Cal-PAT study have also considerably contributed to the TXA literature. In the military setting, additional large retrospective studies including MATTERS-1, MATTERS-2, and PED-TRAX have examined the impact of TXA administration in adult and pediatric combat trauma patients. Importantly, many of these trials include multiple treatments arms and analyses of adverse outcomes, allowing for TXA dose comparisons and therapeutic complication profile characterizations.
We propose a robust PMG with four PICO questions:
PICO Question 1: In adult trauma patients at risk for hemorrhage (P), should Tranexamic Acid (TXA) in the hospital setting (I) versus no TXA (C) be used to decrease mortality or total blood products used (O)?
PICO Question 2: In adult trauma patients at risk for hemorrhage (P), should prehospital TXA (I) versus no prehospital TXA (C) be used to decrease mortality or total blood products used (O)?
PICO Question 3: In adult trauma patients at risk for hemorrhage (P), should a high-dose prescription (2-3g) of TXA (I) versus a low-dose prescription (1g) of TXA (C) be administered to decrease mortality or total blood products used? Does TXA dose impact rates of arterial and venous thromboembolic events (O)?
PICO Question 4: In adult trauma patients (P), should TXA be reserved for severely injured patients in severe shock (I) versus administered to all adult trauma patients at risk for hemorrhagic shock (C) to decrease mortality and total blood products used? Does the use of TXA increase rates of venous and arterial thromboembolic events (O)?
Team members:
• Ryan P. Dumas, MD
• Matthew D. Neal, M.D.
• Jason L. Sperry, MD, MPH
• Matthew E. Kutcher, MD
• Bryan A. Cotton, MD, MPH
• Lucy Z. Kornblith, MD
• Martin Schreiber, MD
• Michael W. Cripps, MD, FACS
• Susan Rowell, MD
• Karim Brohi, MD
• Jeremy W. Cannon, MD, SM, FACS
• Michael Sleet, MD
• Linda Dultz, MD
• Jaswin Sawhney, MD
• Kaushal H. Shah, MD
• Nimitt J. Patel, MD
• Patrick Murphy, MD, MPH, MSc
• Sofya H. Asfaw, MD
• Saamia Shaikh, D.O., Esq.
• Ida Molavi MD, FACS, FRCSC