Crash 2 and Tranexamic Acid

One of the most exciting and underutilized therapies for trauma is tranexamic acid (txa). TXA inhibits the breakdown of clot--it is an anti-fibrinolytic. Is there evidence for using this in trauma patients?

First came the Crash 2 Trial (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; 376: 23–32),

then the subgroup reanalysis (Lancet. 2011 Mar 26;377(9771):1096) showing the benefit of treatment as early as possible.

Recently, the MATTERS trial (Arch Surg. 2012; 147:113-119) was published demonstrating the benefits of TXA in military situations, particularly massive transfusion.

How about an incredible review from the J Trauma (2011; 71(1) Supplement S9)

Then there is this paper describing current military protocol rationale.

To discuss TXA in Trauma, I got to interview Dr. Tim Coats, one of the primary authors of Crash 2.

Here is a List of Resources from the Crash 2 Investigators

This is the official resource page from Crash 2

 

We also discussed the concept of the pragmatic trial...

Future Research in Emergency Medicine: Explanation or Pragmatism

(Emerg Med J 2011;28(12):1004)

Listen to the podcast excerpt on pragmatic trials (mp3--right click the link and choose save-as if you want to download)

In an amazing demonstration of synchronicity, Jeff Guy of the ICU Rounds Podcast put out a tranexamic acid episode on the same day.

Minh Le Cong provided this prehospital protocol for TXA use.

An incredible review article can be found at this citation (Journal of TRAUMA 2011;71(1) July Supplement)

Update...

This article published in J Trauma (74(6), May 2013, p 1587–1598) gives an excellent summary of the current evidence as of 5/2013

Summary: What Do We Know?

* TXA is associated with a 1.5% reduction in 28-day all-cause mortality in adult trauma patients with signs of bleeding (SBP < 90 mm Hg, heart rate > 110 beats per minute, or both, within 8 hours of injury) in a large pragmatic prospective randomized placebo-controlled trial.

* What is critical is the modest effect on the overall population: All-cause mortality was “significantly” reduced from 16.0% to 14·5% (NNT, 67). The risk of death caused by bleeding overall was “significantly” reduced from 5.7% to 4·9% (NNT, 121).

* TXA signal for benefit was in the most severe shock group (admission SBP <= 75 mm Hg), 28-day all-cause mortality of 30.6% for the TXA group versus 35.1% for the placebo group (RR, 0.87; 99% CI 0.76–0.99).

* 1,063 deaths (35%) were caused by bleeding in the CRASH-2 Trial.

* TXA had greatest impact on reduction of death caused by bleeding in the severe shock group (SBP <= 75 mm Hg) (14.9% vs. 18.