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

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.

The Pathophysiology and Management of Hemorrhagic Shock in the Polytrauma Patient

“…Although concerns about CRASH-2 design and methodology persist [ 94 ], the results of the study became widely accepted as definitive, and TXA became recognized as the “anti-hemorrhage” drug carried on many ambulances and medical helicopters [ 95 ]. In fact, data confirm the effectiveness of TXA when selectively administered to seriously injured patients (mean ISS ≥ 30) during the prehospital phase of care [ 96 , 97 ].…”

Study conclude that TXA in severely injured was associated with lower mortality: beware of potential confounders

“…We would like to thank Honore et al for their critical appreciation of our work. They have legitimately dealt with the potential main confounder of our study [1]. The aim of our work was to investigate the effects of preclinical administration of TXA in severely injured patients (ISS TXA 32.4 SD 14.7, Control 32.0 SD 14.7) in a developed healthcare system.…”

“…With great interest, we read the recently published article by Imach et al who concluded that tranexamic acid (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, based on matched pairing using the nationwide German Trauma Register DGU® [ 1 ]. When comparing the data between the two groups (with and without TXA), we observe that patients receiving TXA received significantly more hemostatic agents than the non TXA group (47.8% vs 44.2%, p value = 0.018) [ 1 ]. Hemostatic agents comprised fibrinogen, prothrombin concentrates (PPSB), calcium, factor VII or factor XIII which are all major players in coagulation after severe trauma, particularly fibrinogen [ 1 ].…”

“…When comparing the data between the two groups (with and without TXA), we observe that patients receiving TXA received significantly more hemostatic agents than the non TXA group (47.8% vs 44.2%, p value = 0.018) [ 1 ]. Hemostatic agents comprised fibrinogen, prothrombin concentrates (PPSB), calcium, factor VII or factor XIII which are all major players in coagulation after severe trauma, particularly fibrinogen [ 1 ]. All patients in the database, either with or without TXA in the matched pairs table, had an injury severity score (ISS) above 25 [ 1 ].…”

“…Hemostatic agents comprised fibrinogen, prothrombin concentrates (PPSB), calcium, factor VII or factor XIII which are all major players in coagulation after severe trauma, particularly fibrinogen [ 1 ]. All patients in the database, either with or without TXA in the matched pairs table, had an injury severity score (ISS) above 25 [ 1 ]. Life-threatening coagulopathy is present in almost all patients with an ISS > 25 with hypotension, hypothermia, and acidosis [ 2 ].…”