TXA or not TXA in trauma?

 

CRASH-2 trial came out in 2010 to answer this question:

  • What are the effects of the early administration of a short course of tranexamic acid on death in trauma patients with or at risk of significant haemorrhage?

CRASH-2 trial is a large placebo controlled trial undertaken in 276 hospitals in 40 countries.

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Discussion:

  1. Patients were included if the doctors in charge were not sure whether to give TXA or not. Why? Probably because most of the patients included were not having massive hemorrhage (~70% had SBP>90, blunt type of injuries and GCS 13-15). So this is a study looking at TXA use in patients with mild-moderate hemorrhage.
  2. Death due to bleeding had ARR of 0.8% (4.9% in TXA vs 5.7% in placebo). NNT = 125
  3. No significant difference in the need for surgery and transfusion. TXA group received a mean of 6.06U of blood vs placebo with 6.3U of blood.
  4. Subgroup analysis showed greatest benefit of TXA in patients with SBP <75, RR=0·87 (CI 0·76–0·99).
  5. Subgroup analysis also showed some heterogeneity in TXA use >3 hours from injury. Subsequently, an exploratory analysis was carried out to evaluate mortality due to bleeding in different subgroups of patients.
    – It showed that giving TXA >3 hours from injury lead to increased mortality from bleeding, RR=1.44, (CI 1.21-1.84)

Conclusion

  1. With NNT of 125, TXA does not seem to offer more than usually what we do in mild-moderate hemorrhage in term of mortality due to bleeding. In addition, there are no significant differences between need for surgery, transfusion and blood units.
  2. If you want to give, give it ASAP (within 1 hour of injury).
  3. TXA maybe more useful in more severe hemorrhage.

Reference:

CRASH-2 trial collaborators. 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.

CRASH-2 trial collaborators. The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomised controlled trial. Lancet 2011; 377: 1096–101.

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