Page 28 - Journal of Special Operations Medicine - Winter 2015

deaths were due to hemorrhage, of which two-thirds The CRASH-2 study administered 1g of TXA diluted
resulted from noncompressible hemorrhage. 2 in 100mL of normal saline administered over 10 min-
utes, followed by a second 1g dose administered over
The Clinical Randomization of Antifibrinolytics in Sig- 8 hours. Since the CRASH-2 study is, at present, the
84
nificant Hemorrhage (CRASH-2) trial was a large, mul- strongest evidence for the efficacy of TXA in trauma
tinational, placebo-controlled trial that examined the patients, this dosing technique for TXA is often used.
effect of the administration of TXA on death, vascular The MATTERS study, however, used an IV bolus of
occlusive events, and blood transfusion requirements in TXA rather than the CRASH-2 dosing method. Elec-
trauma patients with, or at risk for, significant hemor- tive surgery studies of TXA have also used IV bolus
rhage. This study found that TXA significantly reduced dosing. 85
the risk for death with few adverse effects.
Simplifying and optimizing the dosing regimen for TXA
The subsequent CRASH-2 subgroup analysis and the would be of benefit to Combat medics who may have
Military Application of Tranexamic Acid in Trauma multiple casualties to care for in a combat scenario.
Emergency Resuscitation (MATTERS) study, both pub-
lished in 2011, strengthened the evidence that TXA Summary
reduces mortality in casualties with significant hemor-
rhage, especially when the medication is administered While the list presented here is by no means a compre-
within the first hour after injury. TXA was subsequently hensive list of all of the research areas of interest in bat-
recommended by the CoTCCC and the DHB for use in tlefield trauma care, much less a list of research needs
selected casualties. 80 across the entire continuum of combat casualty care, it
does provide the collective judgment of the CoTCCC
The CRASH-2 subgroup analysis clearly showed that about the highest priorities for RDT&E that relate to
TXA is most effective at reducing mortality when the battlefield trauma care.
medication is administered within 1 hour of injury. Fur-
ther, multiple papers reporting the use of TXA to reduce Two additional observations should be made regarding
bleeding in elective orthopedic, spinal, and cardiac sur- that point: (1) As the landmark Eastridge et al. 2012
2
geries have clearly shown that TXA is effective at reduc- study convincingly documented, most combat fatalities
ing blood loss in this setting without causing increasing occur in the prehospital phase of care, so research ef-
thromboembolic complications. 81,82 TXA, when used in forts that enable Combat medics, corpsmen, and PJs to
elective surgery, is given either preoperatively or, in or- care for their casualties more effectively will convey the
thopedic surgery, just before tourniquet release. Thus, the highest probability of further reducing the case fatality
TXA is on board and acting before the onset of bleeding. rate and preventable deaths among US Combat casual-
ties; and (2) inasmuch as the mission of the CoTCCC is
There are presently no published studies in trauma pa- to update the TCCC Guidelines as needed, this group
tients that look at TXA administered immediately after has excellent visibility of the most important current re-
wounding as compared with TXA administered 1 hour search questions in battlefield trauma care.
after wounding or not at all. This information is of great
interest to the US Military, since noncompressible hem- Acknowledgments
orrhage is the leading cause of death on the battlefield,
even in a combat theater with relatively short evacua- The authors gratefully acknowledge the research as-
tion times to surgical care. This information will be even sistance provided by Mrs Danielle Davis of the Joint
more important for casualties in an immature combat Trauma System.
theater where evacuations to surgical care may be de-
layed far beyond those currently seen in Afghanistan.
Disclaimer
TXA is a tool has been specifically authorized for com- The opinions or assertions contained herein are the pri-
bat medic use by the Assistant Secretary of Defense for vate views of the authors and are not to be construed as
Health Affairs and it is critically important that the use official or as reflecting the views of the Department of
of this effective, safe, and inexpensive medication be op- the Army or the Department of Defense. This recom-
timized in battlefield trauma care. 80,83 mendation is intended to be a guideline only and is not
a substitute for clinical judgment.
9. (Tie) Evaluate the use of an undiluted IV bolus of
TXA in noncompressible hemorrhage versus the cur- Disclosures
rently used 10-minute infusion of TXA diluted in
100mL of normal saline. The authors have nothing to disclose.

16 Journal of Special Operations Medicine Volume 15, Edition 4/Winter 2015