Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

Keynote webinar | Spotlight on medication adherence

LIVE: Thursday 27th June 2024, 18:00-19:30 (CEST)
Join our expert panel to discover why you need to understand the drivers of non-adherence in your patients, and how you can optimize medication adherence in your clinics to drastically improve patient outcomes.
ADVANCED SEARCH
Log in
Top
Critical Care
Published in: Critical Care 1/2021

Open Access 01-12-2021 | Tranexamic Acid | Research

The impact of prehospital tranexamic acid on mortality and transfusion requirements: match-pair analysis from the nationwide German TraumaRegister DGU®

Authors: Sebastian Imach, Arasch Wafaisade, Rolf Lefering, Andreas Böhmer, Mark Schieren, Victor Suárez, Matthias Fröhlich, TraumaRegister DGU

Published in: Critical Care | Issue 1/2021

Login to get access

Abstract

Background

Outcome data about the use of tranexamic acid (TXA) in civilian patients in mature trauma systems are scarce. The aim of this study was to determine how severely injured patients are affected by the widespread prehospital use of TXA in Germany.

Methods

The international TraumaRegister DGU® was retrospectively analyzed for severely injured patients with risk of bleeding (2015 until 2019) treated with at least one dose of TXA in the prehospital phase (TXA group). These were matched with patients who had not received prehospital TXA (control group), applying propensity score-based matching. Adult patients (≥ 16) admitted to a trauma center in Germany with an Injury Severity Score (ISS) ≥ 9 points were included.

Results

The matching yielded two comparable cohorts (n = 2275 in each group), and the mean ISS was 32.4 ± 14.7 in TXA group vs. 32.0 ± 14.5 in control group (p = 0.378). Around a third in both groups received one dose of TXA after hospital admission. TXA patients were significantly more transfused (p = 0.022), but needed significantly less packed red blood cells (p ≤ 0.001) and fresh frozen plasma (p = 0.023), when transfused. Massive transfusion rate was significantly lower in the TXA group (5.5% versus 7.2%, p = 0.015). Mortality was similar except for early mortality after 6 h (p = 0.004) and 12 h (p = 0.045). Among non-survivors hemorrhage as leading cause of death was less in the TXA group (3.0% vs. 4.3%, p = 0.021). Thromboembolic events were not significantly different between both groups (TXA 6.1%, control 4.9%, p = 0.080).

Conclusion

This is the largest civilian study in which the effect of prehospital TXA use in a mature trauma system has been examined. TXA use in severely injured patients was associated with a significantly lower risk of massive transfusion and lower mortality in the early in-hospital treatment period. Due to repetitive administration, a dose-dependent effect of TXA must be discussed.
Literature
1.
Kauvar DS, Lefering R, Wade CE. Impact of hemorrhage on trauma outcome: an overview of epidemiology, clinical presentations, and therapeutic considerations. J Trauma Acute Care Surg. 2006;60(6):S3–11.CrossRef
2.
Brohi K, Singh J, Heron M, et al. Acute traumatic coagulopathy. J Trauma Acute Care Surg. 2003;54(6):1127–30.CrossRef
3.
Maegele M, Lefering R, Yucel N, et al. Early coagulopathy in multiple injury: an analysis from the German Trauma Registry on 8724 patients. Injury. 2007;38(3):298–304.PubMedCrossRef
4.
Spahn DR, Bouillon B, Cerny V, et al. The European guideline on management of major bleeding and coagulopathy following trauma. Crit Care. 2019;23(1):98.PubMedPubMedCentralCrossRef
5.
Cannon JW, Khan MA, Raja AS, et al. Damage control resuscitation in patients with severe traumatic hemorrhage: a practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2017;82(3):605–17.PubMedCrossRef
6.
Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, platelets, and red blood cells in a 1: 1: 1 vs a 1: 1: 2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA, J Am Med Assoc. 2015;313(5):471–82.CrossRef
7.
Borgman MA, Spinella PC, Perkins JG, et al. The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma Acute Care Surg. 2007;63(4):805–13.CrossRef
8.
Albrecht V, Schäfer N, Stürmer E, et al. Practice management of acute trauma haemorrhage and haemostatic disorders across German trauma centres. Eur J Trauma Emerg Surg. 2017;43(2):201–14.PubMedCrossRef
9.
Inaba K, Rizoli S, Veigas PV, et al. 2014 Consensus conference on viscoelastic test-based transfusion guidelines for early trauma resuscitation: report of the panel. J Trauma Acute Care Surg. 2015;78(6):1220–9.PubMedCrossRef
10.
Novak A, Stanworth SJ, Curry N. Do we still need cryoprecipitate? Cryoprecipitate and fibrinogen concentrate as treatments for major hemorrhage—how do they compare? Expert Rev Hematol. 2018;11(5):351–60.PubMedCrossRef
11.
Wafaisade A, Lefering R, Maegele M, et al. Coagulation management of bleeding trauma patients is changing in German trauma centers: an analysis from the trauma registry of the German Society for Trauma Surgery. J Trauma Acute Care Surg. 2012;72(4):936–42.PubMedCrossRef
12.
Rourke C, Curry N, Khan S, et al. Fibrinogen levels during trauma hemorrhage, response to replacement therapy, and association with patient outcomes. J Thromb Haemost. 2012;10(7):1342–51.PubMedCrossRef
13.
Schöchl H, Frietsch T, Pavelka M, et al. Hyperfibrinolysis after major trauma: differential diagnosis of lysis patterns and prognostic value of thrombelastometry. J Trauma Acute Care Surg. 2009;67(1):125–31.CrossRef
14.
Moore HB, Moore EE, Gonzalez E, et al. Hyperfibrinolysis, physiologic fibrinolysis, and fibrinolysis shutdown: the spectrum of postinjury fibrinolysis and relevance to antifibrinolytic therapy. J Trauma Acute Care Surg. 2014;77(6):811.PubMedPubMedCentralCrossRef
15.
Stein P, Studt J-D, Albrecht R, et al. The impact of prehospital tranexamic acid on blood coagulation in trauma patients. Anesth Analg. 2018;126(2):522–9.PubMedCrossRef
16.
17.
Moore HB, Moore EE, Huebner BR, et al. Tranexamic acid is associated with increased mortality in patients with physiological fibrinolysis. J Surg Res. 2017;220:438–43.PubMedPubMedCentralCrossRef
18.
Meizoso JP, Dudaryk R, Mulder MB, et al. Increased risk of fibrinolysis shutdown among severely injured trauma patients receiving tranexamic acid. J Trauma Acute Care Surg. 2018;84(3):426–32.PubMedCrossRef
19.
Polytrauma Guideline Update Group. Level 3 guideline on the treatment of patients with severe/multiple injuries: AWMF Register-Nr. 012/019. Eur J Trauma Emerg Surg. 2018;44(Suppl 1):3–271.CrossRef
20.
Williams-Johnson J, McDonald A, Strachan GG, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. West Indian Med J. 2010;59(6):612–24.PubMed
21.
CRASH-2 Collaborators. The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomised controlled trial. The Lancet. 2011;377(9771):1096–101.CrossRef
22.
23.
Surgery TRotGSoT. ‘Scoring’study committee of the German Society of Trauma Surgery. Unfallchirurg. 1994;97:230–7.
24.
Ruchholtz S, Lefering R, Lewan U, et al. Implementation of a nationwide trauma network for the care of severely injured patients. J Trauma Acute Care Surg. 2014;76(6):1456–61.PubMedCrossRef
25.
Baker SP, o’Neill B, Haddon W Jr, et al. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma Acute Care Surg. 1974;14(3):187–96.CrossRef
26.
Gennarelli T, Wodzin E. A contemporary injury scale Injury. Int J Care Injured. 2006;37:1083–91.CrossRef
27.
Vincent J-L, De Mendonça A, Cantraine F, et al. Use of the SOFA score to assess the incidence of organ dysfunction/failure in intensive care units: results of a multicenter, prospective study. Crit Care Med. 1998;26(11):1793–800.PubMedCrossRef
28.
Rc BONE. Let’s agree on terminology: definitions of sepsis. Crit Care Med. 1991;19(7):973–6.CrossRef
29.
Lefering R, Huber-Wagner S, Nienaber U, et al. Update of the trauma risk adjustment model of the TraumaRegister DGU™: The Revised Injury Severity Classification, version II. Critical care (London, England). 2014;18:476.CrossRef
30.
Austin PC. Using the standardized difference to compare the prevalence of a binary variable between two groups in observational research. Commun Stat Simul Comput. 2009;38(6):1228–34.CrossRef
31.
Neeki MM, Dong F, Toy J, et al. Safety and efficacy of hospital utilization of tranexamic acid in civilian adult trauma resuscitation. West J Emerg Med. 2020;21(2):217.PubMedPubMedCentralCrossRef
32.
Neeki MM, Dong F, Toy J, et al. Tranexamic acid in civilian trauma care in the California prehospital antifibrinolytic therapy study. West J Emerg Med. 2018;19(6):977.PubMedPubMedCentralCrossRef
33.
Shafi S, Collinsworth AW, Richter KM, et al. Bundles of care for resuscitation from hemorrhagic shock and severe brain injury in trauma patients—translating knowledge into practice. J Trauma Acute Care Surg. 2016;81(4):780–94.PubMedCrossRef
34.
Almuwallad A, Cole E, Ross J, et al. The impact of prehospital TXA on mortality among bleeding trauma patients: A systematic review and meta-analysis. J Trauma Acute Care Surg. 2021;90(5):901–7.PubMedCrossRef
35.
CRASH-3 trial collaborators. Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH-3): a randomised, placebo-controlled trial. Lancet. 2019;394:1713–23.CrossRef
36.
Cole E, Davenport R, Willett K, et al. Tranexamic acid use in severely injured civilian patients and the effects on outcomes: a prospective cohort study. Ann Surg. 2015;261(2):390–4.PubMedCrossRef
37.
Jiménez JJ, Iribarren JL, Brouard M, et al. Safety and effectiveness of two treatment regimes with tranexamic acid to minimize inflammatory response in elective cardiopulmonary bypass patients: a randomized double-blind, dose-dependent, phase IV clinical trial. J Cardiothorac Surg. 2011;6:138.PubMedPubMedCentralCrossRef
38.
Guyette FX, Brown JB, Zenati MS, et al. Tranexamic acid during prehospital transport in patients at risk for hemorrhage after injury: a double-blind, placebo-controlled, randomized Clinical Trial. JAMA Surg. 2020;156:11–20.PubMedCentral
39.
Thorn S, Lefering R, Maegele M, et al. Early prediction of acute traumatic coagulopathy: a validation of the COAST score using the German Trauma Registry. Eur J Trauma Emerg Surg. 2021;47:333–41.PubMedCrossRef
40.
41.
Lier H, Maegele M. Blutungsmanagement: Tranexamsäure in der Präklinik. Pro und Kontra. Notfall + Rettungsmedizin. 2019;22(8):685–95.CrossRef
42.
Rossaint R, Bouillon B, Cerny V, et al. The European guideline on management of major bleeding and coagulopathy following trauma. Crit Care. 2016;20(1):100.PubMedPubMedCentralCrossRef
43.
Grassin-Delyle S, Theusinger O, Albrecht R, et al. Optimisation of the dosage of tranexamic acid in trauma patients with population pharmacokinetic analysis. Anaesthesia. 2018;73(6):719–29.PubMedCrossRef
44.
Johnston LR, Rodriguez CJ, Elster EA, et al. Evaluation of military use of tranexamic acid and associated thromboembolic events. JAMA Surg. 2018;153(2):169–75.PubMedCrossRef
45.
Morrison JJ, Dubose JJ, Rasmussen TE, et al. Military application of tranexamic acid in trauma emergency resuscitation (MATTERs) study. Arch Surg. 2012;147(2):113–9.PubMedCrossRef
46.
Roberts I, Shakur-Still H, Afolabi A, et al. Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial. The Lancet. 2020;395(10241):1927–36.CrossRef
47.
Murkin JM, Falter F, Granton J, et al. High-dose tranexamic acid is associated with nonischemic clinical seizures in cardiac surgical patients. Anesth Analg. 2010;110(2):350–3.PubMedCrossRef
48.
Frimat M, Decambron M, Lebas C, et al. Renal cortical necrosis in postpartum hemorrhage: a case series. Am J Kidney Dis. 2016;68(1):50–7.PubMedCrossRef
49.
Rowell SE, Meier EN, McKnight B, et al. Effect of out-of-hospital tranexamic acid vs placebo on 6-month functional neurologic outcomes in patients with moderate or severe traumatic brain injury. JAMA. 2020;324(10):961–74.PubMedPubMedCentralCrossRef
50.
Mellin-Olsen J, Staender S, Whitaker DK, et al. The Helsinki declaration on patient safety in anaesthesiology. Eur J Anaesthesiol. 2010;27(7):592–7.PubMedCrossRef
51.
Ditzel RM Jr, Anderson JL, Eisenhart WJ, et al. A review of transfusion-and trauma-induced hypocalcemia: is it time to change the lethal triad to the lethal diamond? J Trauma Acute Care Surg. 2020;88(3):434–9.PubMedCrossRef
52.
Brown JB, Neal MD, Guyette FX, et al. Design of the study of tranexamic acid during air medical prehospital transport (STAAMP) trial: addressing the knowledge gaps. Prehosp Emerg Care. 2015;19(1):79–86.PubMedCrossRef
Metadata
Title
The impact of prehospital tranexamic acid on mortality and transfusion requirements: match-pair analysis from the nationwide German TraumaRegister DGU®
Authors
Sebastian Imach
Arasch Wafaisade
Rolf Lefering
Andreas Böhmer
Mark Schieren
Victor Suárez
Matthias Fröhlich
TraumaRegister DGU
Publication date
01-12-2021
Publisher
BioMed Central
Keyword
Tranexamic Acid
Published in
Critical Care / Issue 1/2021
Electronic ISSN: 1364-8535
DOI
https://doi.org/10.1186/s13054-021-03701-7

Other articles of this Issue 1/2021

Critical Care 1/2021 Go to the issue

Research

Norepinephrine potentiates the efficacy of volume expansion on mean systemic pressure in septic shock

Research

Surge effects and survival to hospital discharge in critical care patients with COVID-19 during the early pandemic: a cohort study

Research

The effect of the head-up position on cardiopulmonary resuscitation: a systematic review and meta-analysis

Viewpoint

Optimising the timing of renal replacement therapy in acute kidney injury

Research Letter

Analysis of top influencers in critical care medicine “twitterverse” in the COVID-19 era: a descriptive study

Research

Characteristics and clinical outcomes of culture-negative and culture-positive septic shock: a single-center retrospective cohort study