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Tranexamic acid as part of remote damage-control resuscitation in the prehospital setting: A critical appraisal of the medical literature and available alternatives

Ausset, Sylvain MD; Glassberg, Elon MD, MHA; Nadler, Roy MD; Sunde, Geir MD; Cap, Andrew P. MD, PhD; Hoffmann, Clément MD; Plang, Soryapong MD; Sailliol, Anne MD

Journal of Trauma and Acute Care Surgery: June 2015 - Volume 78 - Issue 6 - p S70–S75
doi: 10.1097/TA.0000000000000640
Review Articles

BACKGROUND Hemorrhage remains the leading cause of preventable trauma-associated mortality. Interventions that improve prehospital hemorrhage control and resuscitation are needed. Tranexamic acid (TXA) has recently been shown to reduce mortality in trauma patients when administered upon hospital admission, and available data suggest that early dosing confers maximum benefit. Data regarding TXA implementation in prehospital trauma care and analyses of alternatives are lacking. This review examines the available evidence that would inform selection of hemostatic interventions to improve outcomes in prehospital trauma management as part of a broader strategy of “remote damage-control resuscitation” (RDCR).

METHODS The medical literature available concerning both the safety and the efficacy of TXA and other hemostatic agents was reviewed.

RESULTS TXA use in surgery was studied in 129 randomized controlled trials, and a meta-analysis was identified. More than 800,000 patients were followed up in large cohort study. In trauma, a large randomized controlled trial, the CRASH-2 study, recruited more than 20,000 patients, and two cohort studies studied more than 1,000 war casualties. In the prehospital setting, the US, French, British, and Israeli militaries as well as the British, Norwegian, and Israeli civilian ambulance services have implemented TXA use as part of RDCR policies.

CONCLUSION Available data support the efficacy and the safety of TXA. High-level evidence supports its use in trauma and strongly suggests that its implementation in the prehospital setting offers a survival advantage to many patients, particularly when evacuation to surgical care may be delayed. TXA plays a central role in the development of RDCR strategies.

From the Department of Anesthesiology and Intensive Care (S.A.), Percy Military Hospital; and Centre de Transfusion Sanguine des Armées rue Raoul Batany (S.P., A.S.), Clamart; and French Military Health Service Academy–Ecole du Val-de-Grâce (C.H.), Paris, France; The Trauma and Combat Medicine Branch (E.G., R.N.), the Surgeon Generals’ Headquarters, Israel Defense Forces Medical Corps, Ramat Gan, Israel; Norwegian Air Ambulance Foundation (G.S.), Drøbak, Norway; and Blood Research Program (A.P.C.), US Army Institute of Surgical Research, JBSA-Fort Sam Houston, Texas.

Submitted: September 2, 2014, Revised: February 15, 2015, Accepted: March 2, 2015.

Presented at the 4th Annual Remote Damage Control Resuscitation Symposium of the Trauma Hemostasis and Oxygenation Research Network, June 9–11, 2014, in Bergen, Norway.

Address for reprints: Sylvain Ausset, MD, Department of Anesthesiology and Intensive Care, Percy Military Hospital, Clamart, France, 101, Avenue Henri Barbusse, BP 406, 92141 Clamart Cedex, France; email: sylvain.ausset@gmail.com.

© 2015 Lippincott Williams & Wilkins, Inc.