‘ASPIRIN’ FOR TRAUMA?
GAINING GROUND SLOWLY
In the more than seven years since CRASH- 2
was published in The Lancet in 2010, TXA
for trauma has been incorporated into U.S.
and U.K. military protocols, is on British and
Australian ambulances, and has been named
by the World Health Organization (WHO)
as among the essential drugs every healthcare
system should have ready. TXA is available in
trauma centers from London to Los Angeles;
however, it hasn’t yet been embraced by U.S.
The New York Times explored the
slow adoption of TXA in a 2012
news article, noting that TXA was
a cheap drug that the U.S. military
felt was saving lives, and referencing
a study estimating it could save 4,000
lives a year in the U.S. The authors
then write, “Its very inexpensiveness
has slowed its entry into American
emergency rooms … Because there
is so little profit in it, the companies
that make it do not champion it.”
In addition to the lack of finan-
cial interest in pushing TXA, a sec-
ond reason for the slow adoption of TXA in
the U.S. has to do with history: Having been
unwittingly influenced at least twice by the
pharmaceutical marketing of wonder drugs to
stop bleeding (NovoSeven and Trasylol), many
physicians aren’t rushing to embrace a third.
A third reason physicians have been slow
to embrace TXA has been a misunderstanding of research coming out of the U.S. military, which has reported favorably on its use
of TXA for combat injuries in Afghanistan.
Military trauma teams were desperate to
save injured soldiers, and so they were routinely expanding the boundaries of trauma
care—giving platelets and plasma; aggressively
applying tourniquets; starting blood transfusions in helicopters and ambulances; and
giving TXA, NovoSeven, and even cryoprecipitate (the frozen, pro-coagulant dregs that
can be spun out of plasma in a centrifuge for
concentrated clotting effect).
Trauma teams in Afghanistan and Iraq were
changing their practice all of the time—it was
a war zone, after all. Naturally, the doctors
involved have been eager to share this costly
experience from foreign battlefields.
Two papers in particular, Military Application of Tranexamic Acid in Trauma Emergency
Resuscitation (MATTERs) and MAT TERs
II both expressed enthusiasm for TXA. 8, 9
Published in 2012, MATTERs reported
that patients who got TXA tended to be more
severely injured than those who didn’t. (This
makes sense; these patients were crashing and
looked awful, and doctors were desperately
reaching for every available tool). Yet, even
though these patients were the worst injured,
they were most likely to survive. 8
So, of 896 patients seen by U.S. and U.K.
trauma teams in Afghanistan, 293 received
TXA. Mortality was 17.4% among those who
got TXA, 23.9% among those who didn’t. 8
This suggests an NNT of seven crashing sick
combat traumas to save one life.
MATTERs II, published a year later,
reported similar findings, and the authors
recommended liberal use of TXA
in severe trauma. 9
However, even though the MATTERs papers associated TXA with
saving lives, it’s only an association:
This wasn’t a placebo-controlled
trial. There can be all sorts of confounding variables.
It’s a crucial point, because the
MATTERs papers also report an
association between receiving TXA
and then developing downstream
deep vein thrombosis or pulmonary embolism. Recall, however,
Because they were as sick/injured as they were,
it’s possible clots were detected following TXA
administration simply because of their level
These tantalizing yet messy observational
trials are difficult to draw conclusions from,
and it’s a somewhat moot point based on the
excellent randomized controlled trials discussed earlier that include 40,000 trauma and
postpartum hemorrhage patients, with no signs
of pathological clotting.
STATEWIDE PROTOCOL CHANGES
The St. Luke’s Hospital EMS system submitted a special project application to the state of
Massachusetts and received approval for five
local EMS agencies (including EasCare and
Alert, and 9-1-1 services for the municipalities
of New Bedford, Acushnet and Fairhaven) to
begin using TXA at the beginning of 2016.
The project was launched in consultation
with our colleagues at Rhode Island Hospital, our nearest trauma center, notably with
the support of Charles Adams, MD, the head
of trauma surgery. It involved training ED
physicians on medical control aspects and
paramedics on field use. All three major participants— the EMS companies, the St. Luke’s
From Roberts I, Vieceli E, Duffield P. TXA. Lancet. Retrieved Nov 28, 2017, from www.thelancet.com/pb/assets/
raw/Lancet/pdfs/TXA-manga.pdf. Illustration courtesy Ian Roberts
Figure 1: TXA is a numbers game
TXA is available in trauma
centers from London to Los
Angeles; however, it hasn’t
yet been embraced by U.S.