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2. Implement TCCC guidelines as the standards for prehospi- 4. Butler FK, et al. Implementing and preserving the advances in
tal combat casualty care with requisite accountability and combat casualty care from Iraq and Afghanistan throughout the
documentation. U.S. Military. J Trauma Acute Care Surg. 2015;79(2):321–326.
3. Consider refining guidance to allow slow IV push of TXA 5. Cap AP, et al. Tranexamic acid for trauma patients: a critical re-
view of the literature. J Trauma. 2011;71(1 suppl):S9–S14.
at the point of injury by medics and providers. 6. Cyklokapro package insert. Groton, CT: Pfizer; 2017.
®
7. Roberts, I, et al. HALT-IT—tranexamic acid for the treatment of
The generalizability of these results is unclear. It is possible gastrointestinal bleeding: study protocol for a randomised con-
that TXA administration rates are higher in other settings. trolled trial. Trials. 2014;15:450.
However, given the low adherence with TXA administration 8. Wellington K, Wagstaff AJ. Tranexamic acid: a review of its use in
in this data set across all subgroups, we believe it is unlikely the management of menorrhagia. Drugs. 2003;63(13):1417–1433.
that a significant increase would be found in other theaters. 9. White A, O’Reilly BF. Oral tranexamic acid in the management of
epistaxis. Clin Otolaryngol Allied Sci. 1988;13(1):11–16.
The fact that prehospital documentation quality remains poor 10. Zahed R, et al. A new and rapid method for epistaxis treatment
hinders our ability to conduct such analyses in other locations. using injectable form of tranexamic acid topically: a randomized
It is possible that provider failure to document TXA adminis- controlled trial. Am J Emerg Med. 2013;31(9):1389–1392.
tration in these registry data understate the true proportions 11. Gharaibeh A, et al. Medical interventions for traumatic hyphema.
of patients receiving this intervention. However, the rates we Cochrane Database Syst Rev. 2011;(1):CD005431.
observed were sufficiently low that we doubt such documenta- 12. Ker K, et al. Effect of tranexamic acid on surgical bleeding: system-
atic review and cumulative meta-analysis. BMJ. 2012;344:e3054.
tion issues would have a material impact on our overall results 13. Rahmani B, Jahadi HR. Comparison of tranexamic acid and
and conclusions. prednisolone in the treatment of traumatic hyphema. A random-
ized clinical trial. Ophthalmology. 1999;106(2):375–379.
14. Myles PS, et al. Tranexamic acid in patients undergoing coronary-
Conclusion artery surgery. N Engl J Med. 2017;376(2):136–148.
Overall, proportions of eligible patients receiving TXA were 15. Tintinalli JE, et al. Tintinalli’s emergency medicine: a comprehen-
low despite emphasis in the guidelines. The reasons for this sive study guide (ed 8). New York, NY: McGraw-Hill Education;
2016.
low adherence to TCCC guidelines are likely multifactorial. 16. Pusateri AE, et al. Tranexamic acid and trauma: current sta-
Future research should seek to identify reasons TXA is not tus and knowledge gaps with recommended research priorities.
given when indicated and to develop training and technology Shock. 2013;39(2):121–126.
to increase prehospital TXA administration. 17. CRASH-2 Trial Collaborators, Shakur H, Roberts I, et al. Ef-
fects of tranexamic acid on death, vascular occlusive events, and
blood transfusion in trauma patients with significant haemor-
Acknowledgments rhage (CRASH-2): a randomised, placebo-controlled trial. Lan-
We thank the Joint Trauma System Data Analysis Branch for cet. 2010;376(9734):23–32.
their efforts with data acquisition. We thank Ms Jessie D. Fer- 18. Morrison JJ, et al. Military Application of Tranexamic Acid in
nandez for her assistance with data management. Trauma Emergency Resuscitation (MATTERs) study. Arch Surg.
2012;147(2):113–119.
Disclaimer 19. Azu MC, et al. Venous thromboembolic events in hospitalized
trauma patients. Am Surg. 2007;73(12):1228-31.
Opinions or assertions contained herein are the private views 20. Lipsky AM, et al. Tranexamic acid in the prehospital setting: Is-
of the authors and are not to be construed as official or as rael Defense Forces’ initial experience. Injury. 2014;45(1):66–70.
reflecting the views of the Department of the Air Force, the 21. Howard JT1, et al. Military use of TXA in combat trauma: Does
Department of the Army, or the Department of Defense. it matter? J Trauma Acute Care Surg. 2017 Jun 9. [Epub ahead of
print]
Disclosures 22. Nadler R, et al. Tranexamic acid at the point of injury: the Israeli
The authors have nothing to disclose. combined civilian and military experience. J Trauma Acute Care
Surg. 2014;77(3 suppl 2):S146–S150.
23. Aedo-Martin D, et al. Use of tranexamic acid in combat casualties.
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