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should focus on pelvic external fixation ± preperitoneal packing. JAMA Neurol. 2021;78(3):338–345.
Finally, prehospital pelvic binder application may be an area for
further process improvement. Importance: The development and expansion of intracranial he-
matoma are associated with adverse outcomes. Use of tranexamic
The use of tranexamic acid in Tactical Combat Casualty acid might limit intracranial hematoma formation, but its asso-
Care: TCCC Proposed Change 20-02 ciation with outcomes of severe traumatic brain injury (TBI) is
unclear. Objective: To assess whether prehospital administration
Brendon Drew, DO; Jonathan D Auten, DO; Andrew P Cap, MD, of tranexamic acid is associated with mortality and functional
PhD; Travis G Deaton, MD; Benjamin Donham, MD; Warren C outcomes in a group of patients with severe TBI. Design, setting,
Dorlac, MD; Joseph J DuBose, MD, FACS, FCCM; Andrew D and participants: This multicenter cohort study is an analysis of
Fisher, MD, PA-C; Alan J Ginn; James Hancock, MD; John B prospectively collected observational data from the Brain Injury:
Holcomb, MD; John Knight, MD; Ryan Knight, MD; Albert Ken Prehospital Registry of Outcome, Treatments and Epidemiology
Koerner, MD; Lanny F Littlejohn, MD; Matthew J Martin, MD; of Cerebral Trauma (BRAIN-PROTECT) study in the Nether-
John Kip Morey; Jonathan J Morrison, MD; Martin A Schreiber, lands. Patients treated for suspected severe TBI by the Dutch He-
MD; Philip C Spinella, MD, FCCM; Benjamin Walrath, MPH, licopter Emergency Medical Services between February 2012 and
MD; Frank K Butler Jr, MD
December 2017 were included. Patients were followed up for 1
J Spec Oper Med. 20(3):36–43. year after inclusion. Data were analyzed from January 10, 2020,
The literature continues to provide strong support for the early to September 10, 2020. Exposures: Administration of tranexamic
use of tranexamic acid (TXA) in severely injured trauma patients. acid during prehospital treatment. Main outcomes and measures:
Questions persist, however, regarding the optimal medical and The primary outcome was 30-day mortality. Secondary outcomes
tactical/logistical use, timing, and dose of this medication, both included mortality at 1 year, functional neurological recovery at
from the published TXA literature and from the TCCC user com- discharge (measured by Glasgow Outcome Scale), and length of
munity. The use of TXA has been explored outside of trauma, hospital stay. Data were also collected on demographic factors,
new dosing strategies have been pursued, and expansion of retro- preinjury medical condition, injury characteristics, operational
spective use data has grown, as well. These questions emphasize characteristics, and prehospital vital parameters. Results: A to-
the need for a reexamination of TXA by the CoTCCC. The most tal of 1827 patients were analyzed, of whom 1283 (70%) were
significant updates to the TCCC Guidelines are (i) including sig- male individuals, and the median (interquartile range) age was 45
nificant traumatic brain injury (TBI) as an indication for TXA, (ii) (23–65) years. In the unadjusted analysis, higher 30-day mortal-
changing the dosing protocol to a single 2g IV/IO administration, ity was observed in patients who received prehospital tranexamic
and (iii) recommending TXA administration via slow IV/IO push. acid (odds ratio [OR], 1.34; 95% CI, 1.16-1.55; p < .001) com-
pared with patients who did not receive prehospital tranexamic
Case series on 2g tranexamic acid flush from the acid. After adjustment for confounders, no association between
75th Ranger Regiment casualty database prehospital administration of tranexamic acid and mortality was
Christopher Patrick Androski, Jr, MD; William Bianchi, DO, MSc; found across the entire cohort of patients. However, a substan-
Douglas L Robinson, DO, MS; Gregory J Zarow, PhD; Charles H tial increase in the odds of 30-day mortality persisted in patients
Moore, MD; Travis G Deaton, MD; Brendon Drew, DO; Simon with severe isolated TBI who received prehospital tranexamic acid
Corona Gonzalez; Ryan M Knight, MD (OR, 4.49; 95% CI, 1.57–12.87; p = .005) and after multiple im-
putations (OR, 2.05; 95% CI, 1.22-3.45; p = .007). Conclusions
J Spec Oper Med. 20(4):85–91. and relevance: This study found that prehospital tranexamic acid
Early tranexamic acid (TXA) administration for resuscitation of administration was associated with increased mortality in patients
critically injured warfighters provides a mortality benefit. The with isolated severe TBI, suggesting the judicious use of the drug
2019 Tactical Combat Casualty Care (TCCC) recommendations when no evidence for extracranial hemorrhage is present.
of a 1g drip over 10 minutes, followed by 1g drip over 8 hours,
is intended to limit potential TXA side-effects, including hypoten- Update on applications and limitations of perioperative
sion, seizures, and anaphylaxis. However, this slow and cumber- tranexamic acid
some TXA infusion protocol is difficult to execute in the tactical Prakash A Patel, MD, FASE, Julie A Wyrobek, MD, Alexander J
care environment. Additionally, the side-effect cautions derive Butwick, MBBS, FRCA, MS, Evan G Pivalizza, MD, Gregory MT
from studies of elderly or cardiothoracic surgery patients, not Hare, MD, PhD, FRCPC, C David Mazer, MD, Susan M Goobie,
young healthy warfighters. Therefore, the 75th Ranger Regiment MD, FRCPC
developed and implemented a 2g intravenous or intraosseous Anesth Analg. 2022;135(3):460–473.
(IV/IO) TXA flush protocol. We report on the first six cases of
this protocol in the history of the Regiment. After-action reports Tranexamic acid (TXA) is a potent antifibrinolytic with docu-
revealed no incidences of post-TXA hypotension, seizures, or ana- mented efficacy in reducing blood loss and allogeneic red blood
phylaxis. Combined, the results of this case series are encouraging cell transfusion in several clinical settings. With a growing empha-
and provide a foundation for larger studies to fully determine the sis on patient blood management, TXA has become an integral
safety of the novel 2g IV/IO TXA flush protocol toward preserv- aspect of perioperative blood conservation strategies. While clin-
ing the lives of traumatically injured warfighters. ical applications of TXA in the perioperative period are expand-
ing, routine use in select clinical scenarios should be supported
Association between prehospital tranexamic acid by evidence for efficacy. Furthermore, questions regarding optimal
administration and outcomes of severe traumatic dosing without increased risk of adverse events such as throm-
brain injury bosis or seizures should be answered. Therefore, ongoing investi-
gations into TXA utilization in cardiac surgery, obstetrics, acute
Sebastiaan M Bossers, MD; Stephan A Loer, PhD; Frank W
Bloemers, PhD; Dennis Den Hartog, PhD; Esther MM Van trauma, orthopedic surgery, neurosurgery, pediatric surgery, and
Lieshout, PhD; Nico Hoogerwerf, PhD; Joukje van der Naalt, other perioperative settings continue. The aim of this review is to
PhD; Anthony R Absalom, MD; Saskia M Peerdeman, PhD; Lo- provide an update on the current applications and limitations of
thar A Schwarte, PhD; Christa Boer, PhD; Patrick Schober, PhD; TXA use in the perioperative period.
for the BRAIN-PROTECT collaborators

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