engleski

Prehospital use of tranexamic acid for damage- control resuscitation in polytraumatised patients

Introduction: Trauma is one of the major health care challenges of our century, claiming more productive life years than any other disease. The ‘lethal triad’ of hypothermia, acidosis and coagulopathy has been recognised as a significant cause of death in polytraumatised patients. Damage control resuscitation should involve prevention of all three components of the ‘lethal triad’. Integration of permissive hypotension, haemostatic resuscitation, and damage control surgery are essential steps in improving survival. Acute coagulopathy of trauma/shock (ACoTS) develops early in the post-injury phase, and is characterised by a systemic anticoagulation and hyperfibrinolysis, with a substantial increase in bleeding rate, transfusion requirements, and mortality. Today, identification of novel mechanisms for ACoTS lead to new drug discovery and therapeutic management of polytraumatised patients. Methods: Tranexamic acid (TXA) prevents plasminogen from binding to fibrin and inhibits the conversion of plasminogen to plasmin. When administered upon hospital admission, TXA reduces mortality in trauma patients. Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage (CRASH-2) Study revealed that early administration of TXA reduced the risk of death in trauma patients compared with that after placebo (4.9% vs. 5.7%, respectively ; P = 0.0077). Additionally, the Military Application of TXA in Trauma Emergency Resuscitation (MATTERs) Study investigated severely traumatised combat casualties treated with either TXA or placebo, along with standard care. Overall mortality rates were 6.5% lower in the TXA group compared with those in the placebo group (P = 0.03). Therefore, in many trauma centers early administration of TXA is considered as an integral step in coagulation management of major trauma patients who are in pronounced shock or at risk of severe bleeding. Conclusion: Improvement of the chain of care for major trauma patients and high quality trauma care decreases the mortality of major trauma. Therefore, interventions that improve prehospital haemorrhage control are needed. As the effect of TXA is time dependent, it is reasonable to initiate antifibrinolytic therapy as soon as possible, potentially in the field. Although, data regarding TXA implementation in prehospital trauma care are lacking, the most recent European Trauma Bleeding Guidelines recommend using TXA en route to the hospital. Furthermore, safety and efficacy of prehospital TXA administration will be investigated in the Prehospital Antifibrinolytics for Traumatic Coagulopathy and Haemorrhage (PATCH) Study. Therefore, we strongly believe that TXA should be implemented as an adjunctive prehospital haemostatic intervention in order to improve outcomes of polytraumatised patients.

polytrauma; acute coagulopathy of trauma/shock; tranexamic acid

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