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Do all trauma patients benefit from tranexamic acid?

Valle, Evan J. MD; Allen, Casey J. MD; Van Haren, Robert M. MD, MSPH; Jouria, Jassin M. MD; Li, Hua MD, PhD; Livingstone, Alan S. MD; Namias, Nicholas MD, MBA; Schulman, Carl I. MD, PhD; Proctor, Kenneth G. PhD

Journal of Trauma and Acute Care Surgery: June 2014 - Volume 76 - Issue 6 - p 1373–1378
doi: 10.1097/TA.0000000000000242
Original Articles

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).

CONCLUSION 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.

LEVEL OF EVIDENCE 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.

Submitted: November 12, 2013, Revised: February 26, 2014, Accepted: February 26, 2014.

This study was presented as a poster at the 72nd annual meeting of the American Association for the Surgery of Trauma and Clinical Congress of Acute Care Surgery, September 2013, in San Francisco, California.

Address for reprints: Kenneth G. Proctor, PhD, Divisions of Trauma and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, University of Miami School of Medicine Ryder Trauma Center, 1800 NW 10th Ave, Miami, FL 33136; email: kproctor@miami.edu.

© 2014 Lippincott Williams & Wilkins, Inc.