use TXA in massive trauma resuscitation

This patient is in hemorrhagic shock as a result of multiple blunt injuries after a recent high-impact blunt trauma. Tranexamic acid is an antifibrinolytic drug that was developed in Japan in 1965. It acts in a reversible and competitive manner on plasminogen, reducing the affinity of plasminogen to fibrin and resulting in reduced conversion of plasminogen to plasmin. It may be beneficial in trauma because it prevents the development of disseminated intravascular coagulation associated with the fibrinolytic phenotype lethal and common among trauma patients. The CRASH-2 trial was a large multinational randomized controlled trial of 20,211 patients across 274 hospitals and 40 countries in 2010 that demonstrated a 9% reduction in relative risk of mortality when tranexamic acid was administered within 3 h to patients with a systolic BP <75 mm Hg and significant hemorrhage or a risk of significant hemorrhage (choice C is correct).

However, when administered late, tranexamic acid can exert detrimental effects when used during the fibrinolytic shutdown phase. This is why it is important to administer early (within 3 h) of injury. The Military Application of Tranexamic Acid in Trauma Emergency Resuscitation Study (MATTERs) trial demonstrated a reduction in in-hospital mortality but no difference in 24-h mortality and higher rates of venous thrombotic events.

Recombinant factor VIIa has been administered mostly in the military and combat setting in the last 20 years. The majority of prospective studies are underpowered and have not shown a statistically significant improvement in mortality (choice A is incorrect).

Prothrombin complex concentrate is indicated only for patients who are receiving anticoagulation that must be reversed because of hemorrhage after trauma (choice B is incorrect). An ongoing randomized controlled trial is testing whether there is benefit to administering prothrombin complex concentrate in patients who are injured not receiving anticoagulation.

Fibrinogen concentrate should be administered only in patients who have fibrinolysis on viscoelastic testing. Even in those patients, many providers prefer cryoprecipitate administration because of the cost of fibrinogen concentrate (choice D is incorrect).12345678

Footnotes

  1. SEEK Questionnaires ↩

  2. Bouzat P, Bosson JL, David JS, Riou B, Duranteau J, Payen JF; PROCOAG study group. Four-factor prothrombin complex concentrate to reduce allogenic blood product transfusion in patients with major trauma, the PROCOAG trial: study protocol for a randomized multicenter double-blind superiority study. Trials. 2021;22(1):634. PubMed ↩

  3. Innerhofer N, Treichl B, Rugg C, et al. First-line administration of fibrinogen concentrate in the bleeding trauma patient: searching for effective dosages and optimal post-treatment levels limiting massive transfusion-further results of the RETIC study. J Clin Med. 2021;10(17):3930. PubMed ↩

  4. Martinowitz U, Kenet G, Segal E, et al. Recombinant activated factor VII for adjunctive hemorrhage control in trauma. J Trauma. 2001;51(3):431-438. PubMed ↩

  5. Mayer SA, Brun NC, Begtrup K, et al; FAST Trial Investigators. Efficacy and safety of recombinant activated factor VII for acute intracerebral hemorrhage. N Engl J Med. 2008;358(20):2127-2137. PubMed ↩

  6. Morrison JJ, Dubose JJ, Rasmussen TE, Midwinter MJ. Military application of tranexamic acid in trauma emergency resuscitation (MATTERs) study. Arch Surg. 2012;147(2):113-119. PubMed ↩

  7. Roberts I, Shakur H, Coats T, et al. The CRASH-2 trial: a randomised controlled trial and economic evaluation of the effects of tranexamic acid on death, vascular occlusive events and transfusion requirement in bleeding trauma patients. Health Technol Assess. 2013;17(10):1-79. PubMed ↩

  8. Spinella PC, Perkins JG, McLaughlin DF, et al. The effect of recombinant activated factor VII on mortality in combat-related casualties with severe trauma and massive transfusion. J Trauma. 2008;64(2):286-293. PubMed ↩