Antifibrinolytics in a rural trauma state: assessing the opportunities

Abstract

BackgroundTranexamic acid (TXA) has demonstrated improved mortality among trauma patients. However, recent evidence from urban US trauma centers has failed to show a benefit among the civilian population. TXA in rural states has not been evaluated. This study aimed to evaluate the current use of TXA in the rural trauma population.MethodsA retrospective observational review at a level 1 trauma center based in a rural environment. Records were reviewed for TXA indications. TXA indication was defined as: systolic blood pressure <90 mm Hg, blood transfusion, or with a clinical concern for ongoing bleeding. Patients were ineligible if the time since injury was >3 hours.Results400 patients were evaluated. 54% of patients met indications for TXA. 14% of these received TXA. 30.4% with an indication for TXA were ineligible due to arrival beyond 3 hours from time of injury. 135 patients arrived as transfers, 265 from the scene. There was no difference in TXA indications between scene and transfers (73 vs 144, p=1). Transfers were more likely to arrive beyond the 3-hour window (59 vs 7, p=0.001). Mortality for patients treated with TXA was 12.5%. This was not significantly different from patients not treated with TXA (19%).DiscussionIn a rural system, long transfers exclude most patients from treatment with TXA. A multicenter rural trauma center study will be needed to better define the optimal use of TXA in rural populations.Level of evidenceLevel IV data: therapeutic/care management.

Pathologic Fibrinolysis is More Common in a Rural Trauma Setting

“…Previous data from our center highlight these challenges; one study identified 54% of patients met clinical indications for treatment with TXA, but 30% of patients would arrive outside of the treatment window. 17 The current study reinforces these findings by demonstrating the high levels of pathologic fibrinolysis. But the current data call into question the practice of empiric TXA treatment in a rural trauma environment.…”

Mortality and Thrombosis in Injured Adults Receiving Tranexamic Acid in the Post-CRASH-2 Era

“…Future studies evaluating TXA use in patients with hemorrhagic injuries may consider work to identify patients where the potential efficacy of TXA use is maximized and exposure to harm is minimized. Identification may be based on clinical characteristics, transport time or modality, or laboratory measurements such as thromboelastography 38,39…”

Geographical Variance in the Use of Tranexamic Acid for Major Trauma Patients

“…While the WHO has added TXA to its list of essential medicines and it is widely available around the world, patients must present to a facility able to transfuse it within three hours of injury [8,30]. Despite being conducted in a developed nation with a mature trauma system, Bardes et al [31] reported that 30.4% of all patients with an indication for TXA arrived to ED outside the 3 h window, deeming them ineligible for treatment [31]. Injured patients in rural settings and in nations with less mature trauma systems take longer to reach tertiary care facilities equipped to deal with their injuries [31,32].…”

“…Despite being conducted in a developed nation with a mature trauma system, Bardes et al [31] reported that 30.4% of all patients with an indication for TXA arrived to ED outside the 3 h window, deeming them ineligible for treatment [31]. Injured patients in rural settings and in nations with less mature trauma systems take longer to reach tertiary care facilities equipped to deal with their injuries [31,32]. This may limit the system’s ability to implement TXA, despite obvious clinical indications.…”