Page 57 - Journal of Special Operations Medicine - Fall 2017

Prehospital Administration of Tranexamic Acid
by Ground Forces in Afghanistan

The Prehospital Trauma Registry Experience

Steven G. Schauer, DO, MS *; Michael D. April, MD, DPhil ; Jason F. Naylor, PA-C ;
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Jonathan Wiese, MD ; Kathy L. Ryan, PhD ; Andrew D. Fisher, MPAS, PA-C ;
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Cord W. Cunningham, MD, MPH ; Noah Mitchell, 68W ; Mark A. Antonacci, MD 9
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ABSTRACT
Background: Tranexamic acid (TXA) was shown to reduce that have advanced prehospital and hospital trauma manage-
overall mortality and death secondary to hemorrhage in a ment. Such interventions include limb tourniquet application,
large prospective study. This intervention is time sensitive. As junctional tourniquets, hemostatic granules, dressings impreg-
such, the Tactical Combat Casualty Care (TCCC) guidelines nated with hemostatic agents, massive transfusion protocols,
recommend use of this low-cost, safe intervention among pa- and early use of the only medication for significant hemorrhage
tients with possible hemorrhagic shock, penetrating trauma in trauma patients: tranexamic acid (trans-4-(aminomethyl)
to the thorax or trunk, or extremity amputation. Objective: cyclohexanecarboxylic acid [TXA]; trade name: Cyklokapron;
Prehospital administration of TXA by ground forces in the Af- Pfizer, http://www.pfizer.com). 4
ghanistan combat theater is described. Methods: We obtained
data from the Prehospital Trauma Registry. We searched for TXA is an antifibrinolytic agent that reduces plasminogen
all patients with documented hypotension, amputation, or activation via competitive inhibition and plasmin activity.
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penetrating trauma to the torso. Results: From January 2013 TXA has similar action to aminocaproic acid but is 10 times
to September 2014, there were 272 patients who met inclusion more potent in vitro. First described in 1966, research has
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criteria. Most injuries (97.8%; n = 266) were battle injuries. examined this agent in many clinical settings, including hemo-
Of the 272 patients who met criteria to receive prehospital philia, menorrhagia, gastrointestinal bleeding, perioperative
TXA, 51 (18.8%) received TXA, whereas the remaining 221 hemorrhage, epistaxis, and traumatic hyphema. 7–14 The only
(81.2%) did not. Higher proportions of patients receiving U.S. Food and Drug Administration–approved indication is
TXA versus patients not receiving TXA received hemostatic for hemophilia during the peridental extraction period. TXA
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dressings, pressure dressings, and tourniquet placement. Con- reduces bleeding and the need for blood transfusions in mul-
versely, the proportion of patients receiving intravenous fluids tiple surgical settings and trauma. In 2011, the Committee
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was higher in the no-TXA group. Conclusion: Overall, pro- on Tactical Combat Casualty Care (TCCC) revised its guide-
portions of eligible patients receiving TXA were low despite lines to include the off-label use and administration of 1g TXA
emphasis in the guidelines. The reasons for this low adherence within 3 hours of traumatic injury where a blood transfusion
to TCCC guidelines are likely multifactorial. Future research was anticipated. 16
should seek to identify reasons TXA is not given when indi-
cated and to develop training and technology to increase pre- The effectiveness of TXA in major trauma has been evaluated
hospital TXA administration. in two large-scale research studies. The first of these was the
multinational Clinical Randomization of an Antifibrinolytic in
Keywords: tranexamic acid; prehospital; trauma; combat; Significant Hemorrhage 2 (CRASH-2) randomized controlled
military; TXA trial. This study assessed the effects of TXA on death, vascular
occlusive events, and the receipt of blood transfusions among
trauma patients with clinical indications of significant blood
loss. TXA use led to a 9% reduction in the relative risk of
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Introduction
death from all causes and a 15% reduction in the risk of death
Uncontrolled hemorrhage is the major cause of mortality from due to bleeding. Furthermore, there was no increase in vas-
combat injuries and remains the leading cause of preventable cular occlusive events. The second study was the Military
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death on the battlefield. The U.S. Military has aggressively Application of Tranexamic Acid in Trauma Emergency Resus-
1–3
pursued multiple treatment modalities targeting hemorrhage citation (MATTERs) retrospective, observational analysis of
*Correspondence to steven.g.schauer.mil@mail.mil
1 MAJ Schauer is the Combat Casualty Care task area medical director at the U.S. Army Institute of Surgical Research (USAISR) and core faculty
for the emergency medicine program at the San Antonio Military Medical Center (SAMMC) in San Antonio, TX. MAJ April is an emergency
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medicine physician and the director of research for the emergency medicine residency program at the SAMMC in San Antonio, TX. MAJ Naylor
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is an emergency medicine fellowship-trained physician assistant and serves as the emergency medical treatment section officer in charge with
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the 28th Combat Support Hospital at Fort Bragg, NC. MAJ Wiese is an emergency medicine physician and residency faculty for the emergency
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medicine residency program at Carl R. Darnall Army Medical Center at Fort Hood, TX. Dr Ryan is the Combat Casualty Care task area
manager at the USAISR in San Antonio, TX. MAJ Fisher is a second-year medical student at Texas A&M University, College of Medicine, and
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previously a physician assistant with the 75th Ranger Regiment. LTC Cunningham is an emergency medicine and emergency medical services
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physician at the USAISR in San Antonio, TX. SSG Mitchell is a Special Operations Combat Medic with the 75th Ranger Regiment at Fort Ben-
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ning, GA. Col Antonacci is an emergency medicine physician, residency core faculty, and department chief with the Department of Emergency
Medicine at the SAMMC in San Antonio, TX.
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