Page 68 - JSOM Spring 2018

in nontraumatized patients undergoing urgent or emergency performed in high-risk patient populations, including patients
surgery. Eleven articles specifically studied the use of TXA in a undergoing spinal surgery, pelvic surgery, arthroplasty, and or-
prehospital trauma population or included specific discussion thopedic surgery. Other patient populations included those with
about TXA use in the prehospital environment. Six articles TBI, hemoptysis, spontaneous bleeding, upper gastrointestinal
specifically studied the use of TXA in trauma patients with bleeding, and undergoing orthotopic liver transplantation. Of
traumatic brain injuries (TBIs) or included specific discussion significance, despite the heterogeneity of the pooled population,
about TXA use in trauma patients with TBIs. Table 1 lists the there was a consistent lack of signal of risk or harm from TXA.
studies and their authors’ conclusions.
Table 2 lists the original 50 articles. We drew three conclusions
We drew three conclusions from these studies: (1) Current evi- from these studies: (1) There are no published studies linking
dence supports TXA as an effective medication in significantly the use of TXA to increased risk of VTE. Even in high-risk
reducing mortality in trauma patients with hemorrhage when populations, there has been no demonstrated increase risk of
administered within 3 hours of injury; (2) studies have shown DVT or VTE with the administration of TXA. (2) There is in-
that TXA administration in the civilian and military prehospi- sufficient evidence, for or against, the increased risk of throm-
tal environment is achievable; and (3) many civilian and mili- boembolic events in trauma patients treated with TXA. (3)
tary services have already integrated TXA into their clinical There are case studies of patients who have had major throm-
practice guidelines. boembolic events while receiving TXA. There is no causal link
to the use of TXA in these cases.
Question 3
A total of 50 articles were obtained by using the search strat- Question 4
egy: 15 systematic reviews and meta-analyses, two RCTs, three A total of 51 articles were obtained using the search strategy:
prospective cohort studies, nine retrospective chart or case re- five RCTs, two systematic reviews and meta-analyses; two
views, 15 review articles or opinion pieces, and six articles that prospective cohort studies, three retrospective cohort studies,
were excluded; thus, there were 44 remaining articles. two retrospective chart reviews, one study using prognostic
models, one economical evaluation article, and 35 review or
The six excluded articles either did not examine the use of TXA opinion articles.
and/or did not report on the incidence of DVT or VTE. Of
the 15 systematic reviews or meta-analyses, none found an in- Twenty-one articles were excluded. Two were published study
creased risk of DVT or VTE. Of note, most of these studies were protocols for TXA administration in patients with subarachnoid

TABLE 1 Studies Reporting Evidence of TXA Use in Trauma Patients and/or Evidence of Prehospital TXA Use in Trauma Patients
Author Favors or Study Reports
Successful Integration of TXA Use Author Undetermined About Use
in Trauma Patients, No. of TXA in Trauma Patients, No. Not Applicable, No.
Study Type (reference No.) (reference No.) (reference No.)
Randomized control trial 3 (26, 38, 42;
2 (3, 43 [CRASH-2 study])
all related to TXA in TBIs)
Retrospective chart review 4 (13, 17, 23, 27)
Prospective cohort 1 (14) 1 (20)
Retrospective cohort 2 (4, 33 [MATTERs study])
Systematic review/meta-analysis 2 (39, 40) 1 (16)
Review article, editorial, 1 (30
perspective 6 (15, 18, 21, 25, 36, 41) 5 (22, 24, 30, 31, 37) [full text unavailable])
Prognostic model 2 (28, 35)
Economic evaluation 1 (29)
Total 20 10 1
CRASH-2, Clinical Randomization of an Antifibrinolytic in Significant Hemorrhage; MATTERs, Military Application of Tranexamic Acid in
Trauma Emergency Resuscitation; TXA, tranexamic acid.
TABLE 2 Studies Reporting the Risk (Incidence) of VTE or DVT Related to Administration of TXA
No Increased Risk of DVT or VTE, No. DVT or VTE Case Report, No. Not Applicable, No.
Study Type (reference No.) (reference No.) (reference No.)
Randomized control trial 2 (3, 60)
Prospective cohort 3 (64, 66, 76)
Systematic review/meta-analysis 15 (45–51, 57–59, 61, 63, 67, 70, 74)
Retrospective case study 9 (55, 62, 68, 79, 80, 85–87, 89)
a
Review article, editorial, 15 (44, 52–54, 56, 65, 71,
perspective 73, 75, 77, 81, 83, 91–93)
Excluded/not applicable 6 (69, 72, 78, 84, 88, 90)
Total 20 9 21
DVT, deep vein thrombosis; TXA, tranexamic acid; VTE, venous thromboembolism.
a There were eight case reports of patients with a thromboembolic event who were receiving TXA, but the studies were not powered and reported
no evidence of causation: menorrhagia/dysfunctional uterine bleeding (n = 2), hemophilia (n = 1), Evan syndrome (n = 1), idiopathic thrombocy-
topenic purpura (n = 1), and pulmonary embolism (n = 2).

64 | JSOM Volume 18, Edition 1/Spring 2018