State-by-state estimates of avoidable trauma mortality with early and liberal versus delayed or restricted administration of tranexamic acid

Abstract

Objective: Early administration of tranexamic acid (TXA) has been shown to save lives in trauma patients, and some U.S. emergency medical systems (EMS) have begun providing this therapy prehospital. Treatment protocols vary from state to state: Some offer TXA broadly to major trauma patients, others reserve it for patients meeting vital sign criteria, and still others defer TXA entirely pending a hospital evaluation. The purpose of this study is to compare the avoidable mortality achievable under each of these strategies, and to report on the various approaches used by EMS.

Methods: We used the National Center for Health Statistics Underlying Cause of Death data to identify a TXA-naïve population of trauma patients who died from 2007 to 2012 due to hemorrhage. We estimated the proportion of deaths where the patient was hypotensive or tachycardic using the National Trauma Data Bank. We used avoidable mortality risk ratios from the landmark CRASH 2 study to calculate lives saved had TXA been given within one hour of injury based on a clinician's gestalt the patient was at risk for significant hemorrhage; had it been reserved only for hypotensive or tachycardic patients; or had it been given between hours one to three of injury, considered here as a surrogate for deferring the question to the receiving hospital.

Results: Had TXA been given within 1 hour of injury, an average of 3409 deaths per year could have been averted nationally. Had TXA been given between one and three hours after injury, 2236 deaths per year could have been averted. Had TXA only been given to either tachycardic or hypotensive trauma patients, 1371 deaths per year could have been averted. Had TXA only been given to hypotensive trauma patients, 616 deaths per year could have been averted. Similar trends are seen at the individual state level. A review of EMS practices found 15 statewide protocols that allow EMS providers to administer TXA for trauma.

Conclusion: Providing early TXA to persons at risk of significant hemorrhage has the potential to prevent many deaths from trauma, yet most states do not offer it in statewide prehospital treatment protocols.

Keywords: EMS; Hemorrhage; Tranexamic acid (TXA); Trauma.

Fig. 1

Flowchart of patients included in the study. CDC’s Underlying Cause of Death data (purple boxes) was used to identify adult deaths from blunt / penetrating trauma. A literature review (see appendix) was used to further estimate that 25% of those trauma deaths were due to bleeding. The National Trauma Data Bank (green boxes) is a smaller data set than the CDC’s but is more detailed and includes vital signs at presentation. It was used to estimate the percent of deaths from blunt or penetrating trauma that presented with hypotension and / or tachycardia

Fig. 2

Avoidable mortality when TXA is given to severe traumas within one hour, which can be considered a surrogate for providing it in prehospital care; when it is only given between hours one and three, which can be considered a surrogate to deferring the decision to a hospital-based evaluation; or when it is provided only for patients with significant vital sign derangements

Fig. 3

A visual guide to which states provide TXA in EMS trauma protocols. States pictured in black provide TXA in statewide trauma protocols. States pictured in red do not provide TXA in statewide trauma protocols. States pictured in yellow generally do not have prehospital treatment protocols at the state level (but may have local county or municipal treatment protocols). The number in each state is estimated avoidable mortality from providing TXA to major traumas within one hour of injury