Elsevier

Injury

Volume 45, Issue 1, January 2014, Pages 66-70
Injury

Tranexamic acid in the prehospital setting: Israel Defense Forces’ initial experience

https://doi.org/10.1016/j.injury.2013.08.025Get rights and content

Abstract

Background

The leading cause of preventable death in the military setting is haemorrhage. Accumulating evidence has established the benefit of tranexamic acid (TXA), an antifibrinolytic, for treating traumatic haemorrhage in the hospital setting. The use of TXA in the prehospital setting, however, has not been previously described. The present study details our initial experience with a field protocol that advances TXA administration to (or as close as possible to) the point of injury.

Methods

We present a series of all casualties treated with TXA by Israel Defense Forces’ (IDF) prehospital advanced life support providers between December 2011 and February 2013. Data were abstracted from the IDF Trauma Registry at the Research Section of the Trauma and Combat Medicine Branch, Surgeon General's Headquarters.

Results

Forty casualties who received TXA in the prehospital setting were identified. Most casualties were male (n = 35; 88%) and young adults (median 28 years). The mechanism of injury was penetrating in 22 cases (55%). TXA was administered earlier than it could have been in the hospital setting without delaying evacuation. There were no reports of adverse outcomes that could be reasonably attributed to TXA. Casualties who received TXA per protocol were sicker than those who received it not per protocol.

Conclusions

We have shown that TXA may be successfully given in the prehospital setting without any apparent delays in evacuation. In light of recent evidence, the ability to give TXA closer to the time of wounding represents an important step towards improving the survival of trauma victims with haemorrhage, even before definitive care is available. While this may be especially relevant in austere combat environments, there is likely benefit in the civilian sector as well. The safety profile of TXA is an important consideration as prehospital personnel tended to overtreat casualties without indications for TXA per protocol. We suggest that TXA be considered a viable option for use by advanced life support providers at or near the point of injury.

Introduction

Haemorrhage is the leading cause of potentially preventable death in the military setting among both regular and special operations forces [1], [2], [3]. While tourniquets, direct pressure, and hemostatic dressings are of proven benefit for accessible bleeding sites, fluid resuscitation and prompt evacuation have been the mainstays for addressing non-compressible haemorrhage in the forward setting. An antifibrinolytic, tranexamic acid (TXA), has recently been shown to be an important part of the hospital-based provider's armamentarium for treatment of traumatic haemorrhage. Its use in the prehospital setting, however, has not yet been evaluated.

In a large, international, hospital-based study of civilian trauma patients suspected of having haemorrhagic shock, TXA was shown to reduce mortality (“CRASH-2”) [4]. Importantly, no increase in vascular occlusive events was observed. A subsequent analysis using the same data made it clear that early administration was crucial, with late administration (>3 h) possibly reducing survival [5].

TXA has also been evaluated in the military field-hospital setting (“MATTERs”) [6]. This retrospective, observational study at a surgical field hospital (role 3) examined the use of TXA in combat victims who received at least 1 unit of packed red blood cells (PRBCs); TXA was administered within 24 h of admission. The authors found that TXA improved survival, especially among massively transfused casualties; the number needed to treat to achieve a mortality benefit in this latter group was 7. In contrast to the prospective, randomized civilian study mentioned above, this observational study in a military setting did find an increased rate of venous thromboembolism (VTE) in casualties treated with TXA, though there were no fatalities attributed to these events.

Because earlier administration of TXA was associated with improved survival, TXA should be strongly considered for use in the prehospital setting, where the time interval from injury to administration can be even further reduced [7].

As part of our comprehensive effort to improve casualty care and eliminate preventable death, the Israel Defense Forces (IDF) approved TXA for prehospital use in trauma in 2011, releasing a treatment protocol for use by IDF advanced life support providers (physicians and paramedics). The present study describes our initial experience with advancing TXA administration to (or as close as possible to) the point of injury. Though this case series is relatively small, we felt it appropriate to publish these preliminary findings because of the potential for saving lives.

Section snippets

IDF TXA protocol for prehospital use in trauma

The IDF protocol for TXA administration was developed at the Trauma & Combat Medicine Branch (TCMB), at the Surgeon General's Headquarters. For scientific input, the TCMB established a task force composed of the country's leading trauma surgeons and haematologists. The protocol was designed to be sensitive at the expense of decreased specificity, to ensure that casualties with possible haemorrhagic shock, especially those who may require massive transfusion, would be included. According to the

Results

From December 27th, 2011, when TXA was first given by an IDF medical provider through February 2013, there were 40 verified reports of TXA use in the prehospital setting.

Demographic information for the casualties is shown in Table 1. Mechanism of injury was penetrating in 22 (55%) cases, including 14 from military assault rifles, 6 from shrapnel, 1 stabbing, and 1 penetrating injury due to a motor vehicle collision. The mechanism was blunt in 18 (45%) cases, including 14 motor vehicle

Discussion

Early administration of TXA in traumatic haemorrhage has been shown to reduce mortality [4], [5], [9], [10], with earlier administration conferring increased benefit [5]. We thus developed a prehospital protocol that enables us to bring TXA to the point of injury, minimizing the elapsed time from injury to TXA administration. This report of our first cases given TXA in the prehospital setting demonstrates the feasibility of such a potentially life-saving protocol. In addition, this report also

Conclusions

We have shown that TXA may be successfully given at or near the point of injury without delaying evacuation. In light of recently published literature, the ability to give TXA closer to the time of wounding represents an important step towards improving the survival of trauma victims with haemorrhage. While this may be especially relevant in austere combat environments, there is likely benefit in the civilian sector as well. The safety profile of TXA is an important consideration as prehospital

Funding source

No funding was received for this work.

Conflicts of interest statement

The authors report that there are no conflicts of interest.

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