Tranexamic acid in the prehospital setting: Israel Defense Forces’ initial experience
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.
References (14)
- et al.
Tranexamic acid for trauma
Lancet
(2011) - et al.
Walking between the drops: Israeli Defense Forces’ fluid resuscitation protocol
J Emerg Med
(2013) - et al.
Death on the battlefield (2001–2011): implications for the future of combat casualty care
J Trauma Acute Care Surg
(2012) - et al.
Injury severity and causes of death from Operation Iraqi Freedom and Operation Enduring Freedom: 2003–2004 versus 2006
J Trauma
(2008) - et al.
Causes of death in U.S Special Operations Forces in the global war on terrorism: 2001–2004
Ann Surg
(2007) - et al.
Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial
Lancet
(2010) - et al.
The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomised controlled trial
Lancet
(2011)
Cited by (62)
Use of Tranexamic Acid in Traumatic Resuscitation in a Prehospital Setting: A Case Report
2021, Air Medical JournalUnjustified Administration in Liberal Use of Tranexamic Acid in Trauma Resuscitation
2021, Journal of Surgical ResearchEfficacy of prehospital administration of tranexamic acid in trauma patients: A meta-analysis of the randomized controlled trials
2018, American Journal of Emergency MedicineCitation Excerpt :Among them 8 studies [19-24] were excluded as per the criteria for meta-analysis [mortality at 24 h and 30 days, and thromboembolic complications] and availability of only abstracts. Among the 8 excluded studies 7 [8,19-22,24] did not have controls and did not assess the outcome measures. One study had controls but did not have outcome measures [23].
High success rate of prehospital and en route cricothyroidotomy performed in the israel defense forces: 20 years of experience
2021, Prehospital and Disaster Medicine
- 1
The first two authors request co-first authorship designation.