Prehospital Tranexamic Acid in Major Pediatric Trauma Within a Physician-Led Emergency Medical Services System: A Multicenter Retrospective Study

Gossiome, Amaury; Claustre, Clément; Fraticelli, Laurie; Jacquet, Landry; Bouchut, Jean‐Christophe; Javouhey, Étienne; Courtil-Teyssedre, Sonia; Taverna, Xavier-Jean; David, Jean-Stéphane; Mercier, Éric; Tazarourte, Karim; Khoury, Carlos El; Benhamed, Axel

doi:10.1097/pcc.0000000000003038

Cited by 3 publications

(10 citation statements)

References 28 publications

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“…Although the IDF CPG uses a lower weight-based dose of TXA for children, there were significant discrepancies from age-adjusted doses of TXA in the current study, as 74% of our pediatric patients received “adult” TXA doses of 1000 mg, which is a deviation from the CPG. Amaury et al (7) also reported that most pediatric patients received a 1,000 mg loading dose of TXA in the prehospital setting, aligning with our findings.…”

Section: Discussionsupporting

confidence: 92%

“…Evidence supporting the administration of TXA in children therefore remains limited, with most studies focusing on feasibility and safety in this population (22). Amaury et al (7) recently described use of TXA in a prehospital registry, reporting its use in up to a third of major pediatric trauma, with inconsistencies in adherence to clinical indications. In a nontraumatic setting, Schertz et al (23) demonstrated that the use of antifibrinolytics, including TXA, was effective in reducing blood products requirements in children undergoing cardiac surgery with cardiopulmonary bypass.…”

Section: Discussionmentioning

confidence: 99%

“…In December 2011, the Israeli Defense Forces Medical Corps (IDF-MC) introduced a TXA clinical practice guideline (CPG) for bleeding patients and was the first health organization to use TXA in the prehospital setting for military and civilian patients (6). Although the preliminary studies demonstrating TXA efficacy did not include pediatric patients (3, 6), TXA use in the pediatric population is becoming more widespread (7). Despite this history, data on the use of TXA in pediatric patients following trauma in the prehospital setting remain scarce (8).…”

mentioning

confidence: 99%

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

Gendler

Gelikas

Talmy

et al. 2023

Pediatric Critical Care Medicine

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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.

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Section: Discussionsupporting

confidence: 92%

Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

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

Gendler

Gelikas

Talmy

et al. 2023

Pediatric Critical Care Medicine

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“…The authors reply: W e thank Cazes et al (1) for their insightful remarks on our work by Gossiome et al (2) published in Pediatric Critical Care Medicine. One concern was whether dispatched mobile medical teams (MMTs) were staffed by adult or pediatric emergency physicians.…”

mentioning

confidence: 93%

“…Despite its widespread availability (75%), respondents in a recent European survey of helicopter emergency medical services reported using it in only 15% of patients (3), far less than what was reported in our study (1) (40.0% of the cohort). The last point that has been raised by Cazes et al (1) questioned the need for further research to validate the use of TXA in children with severe trauma and argued that studies reporting safe use and efficacy in minimizing blood loss may be sufficient to generalize the use of TXA in trauma cases. However, most of studies were conducted in specific surgical settings and no randomized control trial has ever been conducted to rigorously validate TXA use in other pediatric settings.…”

mentioning

confidence: 99%

Prehospital Tranexamic Acid in Major Pediatric Trauma: Only One Third of Severely Injured Children Receive It

Cazes¹,

Balaz²,

Renard³

et al. 2022

Pediatric Critical Care Medicine

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We read with interest the article published in a recent issue of Pediatric Critical Care Medicine by Gossiome et al (1). This work aims to describe the prehospital administration of tranexamic acid (TXA) by mobile medical teams (MMTs) in major pediatric trauma. The findings of the study raise three important questions for us. In France, specialist pediatric MMTs are rare and often limited to one or two per geographical area; such teams are composed of both an emergency physician and nurse with specialist training in pediatrics. Hence, in general, the most common MMTs are not specialized in pediatrics but are called upon to take care of children in the absence of an available or existing pediatric MMTs. Therefore, first, we wondered whether Gossiome et al (1) knew the type of MMT (i.e., pediatric or nonpediatric) that dealt with their cases of pediatric trauma. This information would allow us to compare practices of the two types of MMT. Indeed, at present, TXA is widely used in the care of adults with trauma, but not so in pediatrics. We could thus see whether emergency physicians who regularly use TXA in adults are also more likely to prescribe TXA in children (or the opposite in the absence of pediatric recommendations).Second, regarding the indication for TXA, did Gossiome et al (1) consider the presence of an effusion-as identified by prehospital focused assessment with trauma sonography (FAST)-as a criterion for the appropriateness of using TXA? We note that only 40% of children had a FAST examination, and, in particular, only 34.4% of cases not receiving TXA had a FAST examination. As it stands, there is a risk of misclassifying TXA administration as appropriate or not appropriate. Do the authors know the reasoning behind lack of a FAST examination in their cohort? For example, availability of ultrasound devices in the MMT, or too low a severity of trauma in individual cases (the group of patients who did not receive TXA had a median Injury Severity Score of 6), or lack of training using the FAST examination in children. We think this information would help to better understand the prehospital administrations of TXA.Finally, Gossiome et al (1) concluded that "TXA is used in one third of patients despite the lack of high-level evidence in severely injured children, " suggesting that the use of TXA in major pediatric trauma should perhaps not be so high. As the authors state, there are no large studies proving the benefits of TXA administration in major pediatric trauma. Even so, we do know that TXA is safe at very high doses in children (2), it is effective in limiting total blood loss in pediatric cardiac surgery (3), and it reduces risk of death in adults with bleeding in the context of trauma (4). These observations may be sufficient to consider the use of TXA in major pediatric trauma. Therefore, we wanted to ask the authors their opinion, in the light of their work, as to whether or not

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The authors reply

Benhamed

Gossiome

Tazarourte

2022

Pediatric Critical Care Medicine

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Prehospital Tranexamic Acid in Major Pediatric Trauma Within a Physician-Led Emergency Medical Services System: A Multicenter Retrospective Study

Abstract: Describe prehospital tranexamic acid (TXA) use and appropriateness within a major trauma pediatric population, and identify the factors associated with its use.

Cited by 3 publications

References 28 publications

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

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

Prehospital Tranexamic Acid in Major Pediatric Trauma: Only One Third of Severely Injured Children Receive It

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