Tranexamic Acid in Civilian Trauma Care in the California Prehospital Antifibrinolytic Therapy Study

Michael M. Neeki, DO, MS; Fanglong Dong, PhD; Jake Toy, BA; Reza Vaezazizi, MD; Joe Powell, EMT-P; David Wong, MD; Michael Mousselli, BS; Massoud Rabiei, BS; Alex Jabourian, DO; Nichole Niknafs, DO; Michelle Burgett-Moreno, BA; Richard Vara, RN, BSN; Shanna Kissel, RN, MSN; Xian Luo-Owen, MD, PhD; Karen R. O'Bosky, MD; Daniel Ludi, MD; Karl Sporer, MD; Troy Pennington, DO; Tommy Lee, MD; Rodney Borger, MD; Eugene Kwong, MD


Western J Emerg Med. 2018;19(6):977-986. 

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First, this study was limited by design. The prospective, non-randomized, cohort design did not allow TXA to be administered in a blinded fashion. Prehospital providers and physicians were aware that TXA had been administered, which may have slightly affected the level of care provided. However, given that the primary outcome was mortality, this impact was likely minimal. Additionally, while we did examine the adverse effects of TXA administration and report our findings, the original study was not powered based on the side effects of TXA administration.

Second, this study relied upon prehospital providers' ability to accurately recognize signs of trauma-related hemorrhagic shock in the field, even if active external bleeding was not present. Despite thorough didactic training and distribution of study protocols, high injury acuity and/or inexperience may have resulted in some providers improperly selecting TXA candidates. Incidences of improper exclusion during the initial months were estimated at <4%. Through active troubleshooting, real-time physician support, and additional education sessions, the estimated incidence was reduced to <2% at study conclusion

Third, we acknowledge that we were not able to account for certain potential confounding factors. In the prehospital setting, we did not account for the impact of total EMS transport time, availability of IV access, first responder prehospital interventions, or differences in the transporting provider agency. With regard to transport times, shorter times may have impacted the ability of first responders to establish IV access and/or administer TXA prior to arriving to the trauma center. Differences in transporting provider agency may also have slightly impacted care due to differing of standard operating procedures; however, TXA protocols were uniform. We also acknowledge that multiple receiving trauma centers in different geographic area may have slightly impacted the patient care outcomes. We attempted to mitigate the influence of these factors by matching the majority of TXA group patients with control patients from the same center. Furthermore, there may have been minor differences in ICU LOS between the five-year, retrospective control group and current practice. However, there were no institutional changes in ICU policy that would have affected our outcomes. Without accounting for these factors, minimal inherent differences may exist between the TXA and control groups and limit the generalizability of these results.