The pre-hospital administration of tranexamic acid to patients with multiple injuries and its effects on rotational thrombelastometry: a prospective observational study in pre-hospital emergency medicine

Abstract

Background: Hyperfibrinolysis (HF) is a major contributor to coagulopathy and mortality in trauma patients. This study investigated (i) the rate of HF during the pre-hospital management of patients with multiple injuries and (ii) the effects of pre-hospital tranexamic acid (TxA) administration on the coagulation system.

Methods: From 27 trauma patients with pre-hospital an estimated injury severity score (ISS) ≥16 points blood was obtained at the scene and on admission to the emergency department (ED). All patients received 1 g of TxA after the first blood sample was taken. Rotational thrombelastometry (ROTEM) was performed for both blood samples, and the results were compared. HF was defined as a maximum lysis (ML) >15 % in EXTEM.

Results: The median (min-max) ISS was 17 points (4-50 points). Four patients (15 %) had HF diagnosed via ROTEM at the scene, and 2 patients (7.5 %) had HF diagnosed via ROTEM on admission to the ED. The median ML before TxA administration was 11 % (3-99 %) vs. 10 % after TxA administration (4-18 %; p > 0.05). TxA was administered 37 min (10-85 min) before ED arrival. The ROTEM results before and after TxA administration did not significantly differ. No adverse drug reactions were observed after TxA administration.

Discussion: HF can be present in severely injured patients during pre-hospital care. Antifibrinolytic therapy administered at the scene is a significant time saver. Even in milder trauma fibrinogen can be decreased to critically low levels. Early administration of TxA cannot reverse or entirely stop this decrease.

Conclusions: The pre-hospital use of TxA should be considered for severely injured patients to prevent the worsening of trauma-induced coagulopathy and unnecessarily high fibrinogen consumption.

Trial registration: ClinicalTrials.gov ID NCT01938768 (Registered 5 September 2013).

Keywords: Coagulopathy; Fibrinolysis; Pre-hospital care; Thrombelastometry; Tranexamic acid; Trauma.

Figures

Fig. 1

ML in ROTEM on the scene (prior to TxA administration) and after ED arrival. No significant differences were found before and after the administration of TxA (p > 0.05). In one patient no clot formatted in neither blood sample and therefore ML was not available

Fig. 2

Results of the ROTEM analyses on the scene (prior to TxA administration) and after ED arrival: a CT in EXTEM, INTEM, FIBTEM and APTEM b MCE in EXTEM, INTEM, FIBTEM and APTEM. No significant differences were found before and after the administration of TxA (p > 0.05)