WHAT’S NEW: Greater emphasis on TXA timing
Current practice for the treatment of traumatic hemorrhage includes fluid resuscitation and the administration of blood products. This analysis of the CRASH-2 refines our understanding of TXA, revealing that the earlier it is given after injury, the better the outcome. A 2011 Cochrane review found only one other small RCT (N = 240), which had findings consistent with the CRASH-2 results.7
TXA is easy to administer and to store and does not require refrigeration or reconstitution prior to administration. TXA has been included in both the US and British Army trauma protocols.8 In addition, TXA is used by National Health Service ambulances in the United Kingdom, and given to all adults and teenagers who incur major traumatic injury.8
CAVEATS: Potential for thromboembolic events, need for high time sensitivity
Because the enrollment criteria for the study were based entirely on clinical findings, there may have been some participants who were not actively bleeding. However, this would have been true for both the treatment and placebo groups and, if anything, would have diluted the effects of TXA.
There was no increase in vaso-occlusive events in the CRASH-2 study. However, some studies of TXA have found an increase in instances of pulmonary embolism, deep vein thrombosis, and ureteral obstruction in patients with genitourinary bleeding.3
This analysis showed that early administration of TXA is the key to its success—and highlighted the importance of avoiding giving it more than 3 hours after traumatic injury. Although most of the 40 countries in which the CRASH-2 study was conducted have less well developed trauma systems than those in the United States, a subgroup analysis of patients in Europe, North America, and Australia (n = 1960) still showed a mortality benefit (RR = 0.63; 95% CI, 0.42-0.94).8
CHALLENGES TO IMPLEMENTATION: Bringing TXA into the mainstream
The acceptance of TXA in trauma care guidelines may be one of the biggest barriers to its use. Currently, the American College of Surgeons does not include the use of TXA in its Advanced Trauma Life Support manual.9
Given the short time window for its benefit, TXA may be most appropriate in the prehospital setting. However, there are no studies of its use in this setting. Lack of knowledge and access are also barriers in the emergency setting, as many ED clinicians, particularly in rural settings, may not yet have access to TXA. Physicians in the United Kingdom have tried a variety of methods, including the unorthodox use of comic books targeted to health care providers,10 in an effort to get the word out.
Acknowledgement
The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center for Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center for Research Resources or the National Institutes of Health.
