Efficacy and Safety of Tranexamic Acid in Prehospital Traumatic Hemorrhagic Shock: Outcomes of the Cal-PAT Study

Michael M Neeki, Fanglong Dong, Jake Toy, Reza Vaezazizi, Joe Powell, Nina Jabourian, Alex Jabourian, David Wong, Richard Vara, Kathryn Seiler, Troy W Pennington, Joe Powell, Chris Yoshida-McMath, Shanna Kissel, Katharine Schulz-Costello, Jamish Mistry, Matthew S Surrusco, Karen R O'Bosky, Daved Van Stralen, Daniel Ludi, Karl Sporer, Peter Benson, Eugene Kwong, Richard Pitts, John T Culhane, Rodney Borger, Michael M Neeki, Fanglong Dong, Jake Toy, Reza Vaezazizi, Joe Powell, Nina Jabourian, Alex Jabourian, David Wong, Richard Vara, Kathryn Seiler, Troy W Pennington, Joe Powell, Chris Yoshida-McMath, Shanna Kissel, Katharine Schulz-Costello, Jamish Mistry, Matthew S Surrusco, Karen R O'Bosky, Daved Van Stralen, Daniel Ludi, Karl Sporer, Peter Benson, Eugene Kwong, Richard Pitts, John T Culhane, Rodney Borger

Abstract

Introduction: The California Prehospital Antifibrinolytic Therapy (Cal-PAT) study seeks to assess the safety and impact on patient mortality of tranexamic acid (TXA) administration in cases of trauma-induced hemorrhagic shock. The current study further aimed to assess the feasibility of prehospital TXA administration by paramedics within the framework of North American emergency medicine standards and protocols.

Methods: This is an ongoing multi-centered, prospective, observational cohort study with a retrospective chart-review comparison. Trauma patients identified in the prehospital setting with signs of hemorrhagic shock by first responders were administered one gram of TXA followed by an optional second one-gram dose upon arrival to the hospital, if the patient still met inclusion criteria. Patients administered TXA make up the prehospital intervention group. Control group patients met the same inclusion criteria as TXA candidates and were matched with the prehospital intervention patients based on mechanism of injury, injury severity score, and age. The primary outcomes were mortality, measured at 24 hours, 48 hours, and 28 days. Secondary outcomes measured included the total blood products transfused and any known adverse events associated with TXA administration.

Results: We included 128 patients in the prehospital intervention group and 125 in the control group. Although not statistically significant, the prehospital intervention group trended toward a lower 24-hour mortality rate (3.9% vs 7.2% for intervention and control, respectively, p=0.25), 48-hour mortality rate (6.3% vs 7.2% for intervention and control, respectively, p=0.76), and 28-day mortality rate (6.3% vs 10.4% for intervention and control, respectively, p=0.23). There was no significant difference observed in known adverse events associated with TXA administration in the prehospital intervention group and control group. A reduction in total blood product usage was observed following the administration of TXA (control: 6.95 units; intervention: 4.09 units; p=0.01).

Conclusion: Preliminary evidence from the Cal-PAT study suggests that TXA administration may be safe in the prehospital setting with no significant change in adverse events observed and an associated decreased use of blood products in cases of trauma-induced hemorrhagic shock. Given the current sample size, a statistically significant decrease in mortality was not observed. Additionally, this study demonstrates that it may be feasible for paramedics to identify and safely administer TXA in the prehospital setting.

Conflict of interest statement

Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. No author has professional or financial relationships with any companies that are relevant to this study. There are no conflicts of interest or sources of funding to declare.

Figures

Figure
Figure
Patient exclusion flow chart that compares patient selection in the prehospital intervention group and control group. TXA, tranexamic acid; EMS, emergency medical services.

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