Page 85 - JSOM Fall 2019

concerning TXA administration undermine doubts that its use
will increase this risk. 2,7,12,13 FIGURE 2 Class II activation criteria.
Blunt or penetrating injury to areas other than the class I activa-
Because TXA has been shown to reduce mortality in trauma tion criteria.
patients when administered early in the course of an injury, • >65 years and currently taking an anticoagulant (not aspirin)
as demonstrated by CRASH-2 and MATTERs, and because with signs of injury.
it is so strongly advocated within the Department of Defense • Amputation distal to the wrist or ankle.
• Crush, de-gloving, or mangled extremity.
medical community, this study was designed to find how of- • Open long bone fracture.
ten TXA-eligible patients receive the drug within the civilian • Two or more distal bone fractures.
prehospital setting. • Pregnant patient with blunt abdominal trauma not meeting
other class I criteria (does not include patients with injuries iso-
lated to the fetus).
Methods • Prolonged loss of consciousness.
• Altered mental status.
All data were obtained retrospectively from the Level 1 • GCS 9-14.
Trauma Center database at Cox Medical Center South in • Neurological deficit associated with SCI transferred from an
outlying facility.
Springfield, MO, for patients between October 2015 and Sep- • Fall ≥20 feet.
tember 2017. Cox South serves as a clinical training site for a. Pediatric fall ≥10 feet.
the Special Operations Combat Medic course. In 2017, Cox • MVC, high speed >40 mph.
South Emergency Department received 408 class I and 2036 b. MVC >30 mph with unrestrained children <8 years.
class II traumas from the surrounding areas in southwest MO • MCI or other ATV-like vehicle crash >20 mph.
(for qualifying criteria, see Figures 1 and 2). Patients included • Burns, partial and full thickness, with or without associated
trauma, that do not meet other class I criteria.
in the study were at least 18 years old, sustained a mechanism a. Pediatric burns <15% not meeting other class I criteria.
of trauma, and met one or more of the following criteria: • Near drowning.
1. Systolic blood pressure ≤90mmHg Trauma Team Activation upgrades should be considered for the
2. Respiratory rate ≥30 or ≤10 following co-morbidities in trauma patients ≥65 years of age:
3. Pulse rate ≥130 bpm • Anticoagulant use and bleeding disorders.
• End-stage renal disease; patients requiring dialysis.
• Adults ≥65 years of age with SBP <110 and/or HR >90.
FIGURE 1 Class I activation criteria. ATV, all-terrain vehicle; GCS, Glasgow Coma Scale; MCI, mass casualty
incident; MVC, motor vehicle collision.
Major Trauma Patient with life or limb threatening injuries.
• Systolic Blood Pressure (SBP) at any time <90 and/or clinical
evidence of shock (altered LOC, HR >120 with clinical signs
of shock).
• Age specific hypotension and/or clinical evidence of shock (al- It is important to note that the CRASH-2 criteria had an in-
tered LOC, decreased peripheral pulses, delayed capillary refill). clusion pulse rate of ≥110 bpm. Our study raised this cut-off
a. 0–12 months SBP should be <70. to 130 bpm, because some of the ambulances were not ad-
b. 1–10 years SBP should be 70 + (age in years × 2). vised to administer the drug if the rate was <130 bpm and no
c. 10 + years SBP should be <90. ambulance crews had a higher threshold for administration.
d. Consider shock if blood products were given or if ≥40cc/kg
crystalloid bolus administered to maintain vital signs. CRASH-2 also included patients suspected to be 16 years of
• Child ≤2 years with CPR in progress. age or older, and we excluded all patients under 18 years of
• Respiratory rate <10 or >29. age. We also only included patients who were coming directly
• Penetrating injury to head, neck, torso, extremities proximal to from emergency medical services (EMS) systems, whether
elbow and knee (t-shirt/boxer shorts area).
• Flail chest, intubation at scene, airway compromise or obstruc- by ambulance or helicopter, and did not include patients
tion, suspected tension/hemo/pneumothorax. who were transfers from another facility. All crews included
• Orthopedic injuries: in the study were confirmed to carry TXA during the time
a. Two or more proximal long-bone fractures (femur/humerus). period of our study. At least one of the authors personally
b. Extremity trauma with loss of distal pulse. reviewed every patient chart included to verify patients did
c. Amputation proximal to wrist or ankle.
d. Pelvic fracture (not to include hip fractures). or did not receive the drug. We suspected that the time an
• GCS ≤8. advanced life support (ALS) crew is with a patient can play
• Open or depressed skull fracture. a significant factor in whether a patient receives TXA, so we
• Paralysis or signs of spinal cord/cranial nerve injury. also determined the average and median times an ALS crew
• Any hemorrhage control issue:
a. Active or uncontrolled hemorrhage. (whether by ambulance or helicopter) was with a patient and
b. Bleeding controlled by a tourniquet. the standard deviation of both categories. All data was stored
• Facility transfer with patient requiring blood or blood pressure and analyzed through an Excel program (Excel 2016 MSO
support. [16.0.4639.1000] 32-bit).
• Severe burn with or without associated trauma
a. Partial or full thickness burn (2nd or 3rd degree).
b. Adult burn >20% BSA. Results
c. >50 years with >10% BSA.
d. Pediatric burn >15% BSA. Our results found that only 5 of 247 TXA-qualifying trauma
e. Signs of inhalation injury. patients actually received the drug while in the prehospital set-
• Drowning with resuscitation in progress.
ting. More significantly, only 2 qualifying patients traveling
BSA, burn surface area; CPR, cardiopulmonary resuscitation; GCS, Glasgow via a ground crew received the drug before or during direct
Coma Scale; HR, heart rate; LOC, loss of consciousness. transportation to the receiving facility (Table 1).

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