Page 86 - JSOM Fall 2019

TABLE 1 Total Number of Occurrences TABLE 2 Time Chart
Unit Type Total, n TXA Received, n % of Total Scene Time, Transit Time, Total Time,
Ground EMS 204 2 0.98 min min min
Air evacuation 43 3 6.97 Overall
EMS, emergency medical services; TXA, tranexamic acid. SD 13.13 15.52
Median 18 17
Ground EMS
There were 44 patients who qualified for the study but were Average 19.96 21.69 41.65
excluded because they were either transported by a crew that SD 10.51 16.38
did not carry TXA, and thus had no possibility of receiving Median 18 15
it, or they were transported after already having received it at Air evacuation
another facility. Two charts did not include scene departure Average 27.67 19.56 47.23
times or arrival-to-facility times and were excluded from the
statistical analyses regarding time in transit and time with pa- SD 20.63 10.46
tient (Figures 1 and 2). Median 22 19
EMS, emergency medical services; SD, standard deviation.

Discussion
Nearly all prehospital staff included in the study have verifi-
ably received education on TXA, CRASH-2, and the MAT- of administration. However, a large standard deviation in all
TERs study and have undergone extensive simulation-based patient time segments for both groups (26.89 min vs 31.09
evaluation where they demonstrated their ability to recognize min) may imply the existence of confounding factors with this
the indications and administer the medication. The conclusion conclusion.
that prehospital staff are unaware of the benefits of TXA is
invalid. Last, TXA administration is contraindicated for patients with
some conditions, including traumatic brain injury and throm-
It is unclear why EMS crews are not administering TXA more boembolic or cardiac rhythm disease.
often to patients who qualify. However, there are several hy-
potheses. First, prehospital staff prioritize TXA below that of Our study is retrospective, and the sample size is relatively
other interventions such as hemorrhage control, thoracic oc- small. This limits our study. Additionally, there is a slight vari-
clusive dressings, needle decompression, and evacuation. ation in indication for TXA administration between ALS sys-
tems in our region. We included patients who met CRASH-2
Second, a weakness cited by the MATTERs authors of the criteria for blood pressure and respirations. We excluded pa-
CRASH-2 study includes patients for whom TXA is unnec- tients who had a heart rate <130 bpm, which deviates from
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essary although they meet criteria for inclusion. An example CRASH-2 with an inclusion rate of 110 bpm. The impact of
could include a patient who sustains a head injury with scalp this might result in a higher rate of TXA administration in our
laceration. When EMS personnel arrive, the bleeding has been population than if CRASH-2 criteria had been followed.
controlled but the patient has an elevated pulse, preexisting
hypotension, or increased respiratory rate. Although this pa- Strengths of our study include the elimination of possible tech-
tient displays objective indicators for TXA administration, the nical error inherent in registry program use. Every chart was
physiologic deficit for which TXA is useful does not exist in personally reviewed by one of the authors.
the opinion of the provider.
Conclusion
Another explanation could be that TXA administration is not
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considered by the provider. Schauer et al. noted in their study Our study highlights a difference in behavior between Special
that patients with more external hemorrhaging had higher Operations and civilian prehospital medical practice. There
rates of TXA administration, implying that visualization of are many reasons why TXA might not be given to a qualify-
hemorrhage plays a key factor in provider recognition. ing trauma patient. Further research should include the ex-
tent each of the possibilities plays in the prevention of TXA
Additionally, the administration of TXA is complex. TXA is use and if lack of use is justified. A questionnaire survey of
approved for administration in a 100mL bolus over 10 min- EMS-ground paramedics and flight crews to understand their
utes. Although the administration by slow intravenous push reasoning as to why they would not administer TXA to a qual-
has been advocated by Schauer et al., this practice, which we ifying patient is likely a proper next step.
have subsequently adopted, has a risk of causing hypoten-
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sion. The Tactical Combat Casualty Care guidelines recom- TXA remains controversial but its benefits should not be ig-
mend administering 1g of TXA in 100mL of 0.9% saline over nored. This study highlights a lack of engagement within the
10 minutes, with the intent of avoiding hypotension, which civilian prehospital community with regard to TXA. Because
could be associated with rapid administration. 15 military trauma care has always preceded civilian trauma de-
velopment, the Special Operations medical community should
Table 2 shows that average ALS ground personnel patient continue to evaluate and advocate the efficacy of this interven-
contact time was just over 41 minutes. TXA administration tion if evidence continues to demonstrate a benefit.
was higher in patients transported by air despite insignifi-
cant increase in patient contact time. This implies that patient Disclosure
contact time should not be considered justification for lack The authors have nothing to disclose.

84 | JSOM Volume 19, Edition 3 / Fall 2019