ED and the Rhode Island Hospital trauma
services—collaborated in tracking data and
outcomes. (We did so because as a new project it’s worthy of monitoring; it was not an
experimental or research undertaking.)
Eligible patients were identified based on
a modified version of the CRASH- 2 protocol: Those with blunt or penetrating mechanisms suffered in the past three hours, appear
age 16 or over and who show signs of internal hemorrhage (i.e., a systolic blood pressure
less than 90 mmHg or a pulse of greater than
110 beats per minute) or who are considered
to be at high risk of significant hemorrhage.
Note that even a patient with normal vital
signs is eligible, as long as the paramedic
believes they are at high risk of hemorrhaging. This is a field call that’s made immediately.
Many patients thus may receive their 1 gram
of IV TXA over about 10 minutes and yet,
with the tests of time and computed tomography, declare themselves to not be hemorrhaging after all.
But that’s OK, because this all-comers treatment approach, employed in CRASH- 2 across
Europe, Africa and Asia, led to survival benefit without adverse outcomes. (CRASH- 2 gave
TXA up to eight hours out from the injury
and found that after the 3-hour mark, it could
be harmful in some cases. 10)
Some have questioned this more liberal protocol. There have been suggestions that TXA
should be reserved only for crashing patients
receiving blood transfusions, for example, or
that it should only be given after blood tests
suggesting coagulopathy. 11–15
But as The Lancet’s CRASH- 2 authors
note—and advocate for in an over-the-top
comic book drama (see Figure 1, p. 4)—
TXA treatment is a numbers game: Critical,
exsanguinating-in-front-of-me patients are
far rarer than those who arrive meta-stable,
but actually have occult internal hemorrhage. 16
One way to think of this is that TXA has
been thought to reduce risk of bleeding to
death by about one-third. 16 So, if a patient
has a 30% chance of bleeding to death, giving TXA takes it down to a 20% chance. If a
patient has a 3% chance of bleeding to death,
giving TXA takes it down to 2%. The vast
majority of the public health benefit across
hundreds of thousands of patients would be
lost if this medicine, which is arguably safer
in trauma than normal saline, 17 isn’t provided broadly.
What happened to the patient at the bar
with the multiple stab wounds? He received
TXA and strong supportive trauma care. His
chest was vented to relieve a tension pneu-
mothorax and his life was just barely saved by
Massachusetts paramedics and Rhode Island
ED and trauma teams.
His first few hours were so tenuous that this
man—the first to receive prehospital TXA in
our protocol—is somewhat legendary in local
EMS circles. Many agree with Brian Giorgi-anni, a paramedic and the St. Luke’s Hospital EMS coordinator in charge of the TXA
project, who insists, “TXA saved that guy’s
life.” (Disagreeing and trying to argue that
technically we can never know that for sure
is usually met with a silencing wave.)
In spring 2017, the data was presented to
the Massachusetts Medical Services Committee (MSC) and included more than 40
patients treated with TXA, including gunshot wounds, rollover MVCs and falls off of
buildings. The physicians on the MSC voted
for an emergency update of the state EMS
That same spring, after many months of
receiving southern Massachusetts trauma
patients who’d been treated with TXA in the
field, Rhode Island state protocols were also
updated to include prehospital TXA.
I’ve done some informal, back-of-the-envelope
math, trying to guess how many lives prehospital use of TXA might save. In 2012, there
were 3,053 trauma deaths in Massachusetts.
Assuming that half of these deaths occurred
on scene (which is in line with national averages), and that half of the remaining patients
died of internal bleeding, a 2% survival benefit from TXA might save 15 Massachusetts
lives a year.
That’s not a peer-reviewed number, but
it’s in the ballpark. That’s pretty exciting for
something that’s arguably safer than normal saline—and almost as cheap. It may be
time to start thinking of TXA as “aspirin” for
Matt Bivens, MD, is an emergency medicine attending physician at St. Luke’s Hospital in New Bedford, Mass., where
he’s also the hospital’s EMS medical director. He’s also an
emergency medicine attending physician at Beth Israel Deaconess Medical Center in Boston, and holds an academic
appointment at Harvard Medical School as an instructor in
clinical medicine. He has no financial interests in anything
discussed in this article.
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