Prehospital Tranexamic Acid Administration in Pediatric Trauma Patients: A Propensity-Matched Analysis of the Israeli Defense Forces Registry

Abstract

OBJECTIVES:Tranexamic acid (TXA) administration confers a survival benefit in bleeding trauma patients; however, data regarding its use in pediatric patients are limited. This study evaluates the prehospital treatment with TXA in pediatric trauma patients treated by the Israel Defense Forces Medical Corps (IDF-MC). DESIGN:Retrospective, cohort study using the Israel Defense Forces registry, 2011-2021. PATIENTS:Pediatric trauma patients less than 18 years old. We excluded patients pronounced dead at the scene. INTERVENTIONS: None.SETTING: All cases of pediatric trauma in the registry were assessed for treatment with TXA. Propensity score matching was used to assess the association between prehospital TXA administration and mortality. MEASUREMENTS AND MAIN RESULTS:Overall, 911 pediatric trauma patients were treated with TXA by the IDF-MC teams; the median (interquartile) age was 10 years (5-15 yr), and 72.8% were male. Seventy patients (7.6%) received TXA, with 52 of 70 (74%) receiving a 1,000 mg dose (range 200-1,000 mg). There were no prehospital adverse events associated with the use of TXA (upper limit of 95% CI for 0/70 is 4.3%). Compared with pediatric patients who did not receive TXA, patients receiving TXA were more likely to suffer from shock (40% vs 10.7%; p < 0.001), sustain more penetrating injuries (72.9% vs 31.7%; p < 0.001), be treated with plasma or crystalloids (62.9% vs 11.4%; p < 0.001), and undergo more lifesaving interventions (24.3% vs 6.2%; p < 0.001). The propensity score matching failed to identify an association between TXA and lesser odds of mortality, although a lack of effect (or even adverse effect) could not be excluded (non-TXA: 7.1% vs TXA: 4.3%, odds ratio = 0.584; 95% CI 0.084-3.143; p = 0.718). CONCLUSIONS:Although prehospital TXA administration in the pediatric population is feasible with adverse event rate under 5%, more research is needed to determine the appropriate approach to pediatric hemostatic resuscitation and the role of TXA in this population.

Damage-control resuscitation in pediatric trauma: What you need to know

“…2) These data are limited by use of multiple antifibrinolytic agents, inclusion of children with medical and surgical bleeding etiology, and uncommon antifibrinolytic use. In addition, Gendler and colleagues 42 have published the Israeli Defense Forces Medical Corps (IDF-MC) experience in utilization of prehospital TXA in pediatric trauma. From 2011 to 2021, 70 of 911 patients (<18 years of age) received TXA.…”

“…Intravenous hemostatic adjuncts also include coagulation factor concentrates such as rFVIIa, fibrinogen and prothrombin complex concentrates. While these agents are used by some practitioners, recent guidelines state there is insufficient evidence for 42 the routine empiric use of these products due to insufficient evidence regarding their efficacy and safety. 8 Cryoprecipitate may be an important hemostatic adjunct to consider since it includes fibrinogen, factors VIII, XIII, and VWF, which are important for fibrin formation, platelet adhesion and aggregation, in addition to reducing fibrinolysis.…”

Adopting a culture of remote damage control resuscitation in the military: Insights from the Israel defense forces decade of experience

“…23 As has been previously reported, 23,24 TXA has since been consistently used in the IDF for the treatment of both adult and pediatric casualties. 25 The indications for the use of TXA have remained relatively unchanged over the last decade, and it is currently indicated for any penetrating torso or junctional injury as well as in trauma patients with signs of profound shock (Figure 3). 26 In contrast to the current Tactical Combat Casualty Care Guidelines (TCCC), 27 traumatic brain injury is not currently a criterion for TXA administration, and our dosage recommendations have remained at 1 g intravenously in the prehospital setting.…”

“…The IDF‐MC began using tranexamic acid (TXA) in August 2011 after the publication of the CRASH‐2 trial 22 demonstrated its effectiveness in reducing mortality from bleeding among trauma patients 23 . As has been previously reported, 23,24 TXA has since been consistently used in the IDF for the treatment of both adult and pediatric casualties 25 . The indications for the use of TXA have remained relatively unchanged over the last decade, and it is currently indicated for any penetrating torso or junctional injury as well as in trauma patients with signs of profound shock (Figure 3).…”