Background: Trauma is one of the leading causes of death worldwide, with acute blood loss being the cause of death for nearly one third of in-hospital trauma deaths. In response to trauma the clotting cascade begins clotting to stop acute hemorrhaging with subsequent fibrinolysis to maintain proper hemostasis. Tranexamic acid (TXA), an anti-fibrinolytic, has been used in elective surgeries to decrease blood loss. TXA does not currently have widespread use in United States emergency departments or pre-hospital settings. Recombinant Factor VIIa has been used in United States trauma centers but has not demonstrated an improvement in mortality. No randomized control trials have proven to be effective in decreasing mortality from blood loss in trauma patients. Will the administration of tranexamic acid have an effect on mortality due to hemorrhage in trauma patients?
Method: An exhaustive search was conducted using Medline-OVID, CINAHL, EBMR Multifile, and Web of Science using the keywords: trauma, wounds and injuries, and tranexamic acid. Relevant articles were assessed for quality using GRADE. A search on the NIH clinical trials site reveals there are no trials currently registered relating to the use of tranexamic acid (TXA) in trauma patients.
Results: Two studies met inclusion criteria and were included in this systematic review. A randomized, double blind, placebo-controlled trial with 20 211 participants demonstrated a statistically significant reduction in all-cause mortality with no increase in vascular occlusive events when TXA was administered. A retrospective observational study with 896 participants demonstrated a statistically significant reduction in mortality when TXA was administered, with the greatest benefit witnessed in those receiving a massive transfusion. In addition, the cohort receiving TXA also demonstrated a decrease in coagulopathies. The patients receiving TXA were also more severely injured.
Conclusion: TXA has been shown to reduce mortality from acute blood loss if given within three hours and the greatest benefit is conferred if administration is within the first hour. There was no definitive evidence of increased risk of blood clots or death from clotting events. In addition, the low cost of TXA makes the drug affordable for urban and rural emergency departments as well as EMS. A strong recommendation can be made for the use of TXA in trauma. More research is needed to determine the precise mechanism of action in trauma.
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