DWR
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Out of curiosity is anyone carrying TXA (Tranexamic acid) in the field? My agency has it for our critical care units and now it's being considered for EMS. Thoughts?
TXA
- Thread starter DWR
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We carry it, and give it based on the CRASH-2 guidelines, i.e. recent traumatic injury, HR > 110 or SBP < 90 at any point, believed due to hemorrhage. CRASH-2 showed no real evidence of harm when given early post-injury in a heterogenous group. The MATTERS study showed even greater benefit in a military population with a more severely traumatised group of patients.
We don't give it in non-traumatic injuries, e.g. variceal disease, vaginal hemorrhage, epistaxis, etc., although I've seen it used in the ER for other indications.
http://www.ncbi.nlm.nih.gov/pubmed/23670117
http://www.ncbi.nlm.nih.gov/pubmed/22006852
http://www.ncbi.nlm.nih.gov/pubmed/25412319
http://www.ncbi.nlm.nih.gov/pubmed/22968527
http://www.ncbi.nlm.nih.gov/pubmed/20554319
Anjel
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I take it for other reasons. We do not carry it. The docs around here don't like it and roll their eyes when you tell them that another facility gave it.
It has mixed reviews I guess. I haven't read any of the studies though.
It has mixed reviews I guess. I haven't read any of the studies though.
OP
OP
DWR
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I appreciate the input from everyone. More or less are you guys using it as common practice? I'm in an area of the US that has a pretty robust knife and gun club and I don't really see some of the old paramedics accepting TXA as an option (which is no different then implementing any other thing). Have you guys seen positive outcomes?
cprted
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My agency. Keep in mind in Canadaland, BLS here is called "Primary Care Paramedic." It a 600 hour of classroom plus 160 hours of field practicum program. Things are a little different north of the 49
DesertMedic66
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I just saw this in one of our supervisors office, I wasn't able to ask if we are going to be doing a study on it or what:
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If we do get it I think it'll be received alright since it's a "sexy" intervention. Everyone got all excited about Ketamine while actively resisting the implementation of a community paramedic program.
Airlinepilotmedic
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I work for a transporting Fire Dept in the ICEMA region of SoCal. We are the first agency to start caring TXA I think in the state, but for sure SoCal. We are all excited to have it, due to the high number of traumas in our area GSW, Stabbings, TC, ect... We started last months and are spearheading the study with Arrowhead Regional Medical Center. I will keep yall posted on how the study is going.
A few people are asking if it works, well, I think that's been answered already. If you look at CRASH-2, they enrolled 20,000 + patients, in over 250 hospitals, in more than 20 different countries. It's a pretty huge trial, and the inclusion criteria were very broad, and amenable to transfer to prehospital care. The physician simply had to see tachycardia or hypotension, and believe it was due to hemorrhage.
What's concerning about it, is that the benefit is time-dependent. Patients treated in the first hour fair best, patients treated in hours 2 - 3 receive less benefit, and and 3 hours + there's harm. So, if you are giving this, you need to be aware that the injury needs to be recent, because it's dangerous in injuries past the 3 hour mark.
What's concerning about it, is that the benefit is time-dependent. Patients treated in the first hour fair best, patients treated in hours 2 - 3 receive less benefit, and and 3 hours + there's harm. So, if you are giving this, you need to be aware that the injury needs to be recent, because it's dangerous in injuries past the 3 hour mark.
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I think TXA sounds quite promising and is certainly something to look at, particularly as it may be a more time sensitive medication that EMS should be getting on board early. I do wonder how often we would end up using it in the field. I don't feel like I personally see a ton of multi system trauma with suspected hemorrhage and tachycardia/hypotension. Obviously this is very system and white cloud dependent.
The MATTERs study has some really interesting results regarding TXA administration prehospitally in patients who also received blood transfusions. The cool thing from that study is that it seemed to indicate patients more severely injured and in need of massive transfusion actually saw a bigger benefit from TXA. Pennsylvania is working on the STAAMP trial for TXA as well as we speak.
The MATTERs study has some really interesting results regarding TXA administration prehospitally in patients who also received blood transfusions. The cool thing from that study is that it seemed to indicate patients more severely injured and in need of massive transfusion actually saw a bigger benefit from TXA. Pennsylvania is working on the STAAMP trial for TXA as well as we speak.
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The truth is that most of us don't see much of that type of trauma. As a fraction of EMS responses, it's actually quite uncommon.
I have a feeling that as more experience is gained with TXA we'll probably see that it matters little when it is given, as long as it is within a certain window (say, <90 min from injury).
We are. Supposedly mandatory training soon. But, I have heard not every medic will be getting it.
Agreed. But the NNT looks pretty low, if you read the previously published papers.
If you look at the CRASH-2 paper, that's sort of the general idea. The biggest benefit was in patients treated in the first hour. This decreased in the second and third hours, and converted to an increased rate of death at the 3 hour point. I think the more surprising finding was that they couldn't identify a lot of harm in the first three hours. There wasn't an obvious high-risk subgroup identified, despite its rather indiscriminate use in largely undifferentiated patients.
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I think it will definitely make it's way into EMS in certain areas however I think certain areas may not benefit from it. Those with short transports, read <30 at the furthest reaches of their area have other things to get done. Our TC here gives it and the consensus is that because the vast majority of our transports are 10 minutes or less (with the longest being 30 minutes and even then those calls usually get HEMS co-dispatched and they carry it) we should be more focused on getting the patient packaged, stripped and prepped for the trauma team rather then focusing on the "sexy" interventions as someone else put it earlier.
It's not uncommon that we get a bad trauma and are barely getting a second line secured as we back into the bay.
It's not uncommon that we get a bad trauma and are barely getting a second line secured as we back into the bay.
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My point was that there is still a lot we don't know about how and when to use TXA in trauma. More experience may show that its benefit is more related to other factors than to timing of administration.
CRASH-2 had some problems and probably raised at least as many questions as answers....it really didn't give us much useful info. The military trials were much better done, but still didn't tell us anything about how or if it should be used prehospital.
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Brandon O
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One of my concerns is that previously, we could pretty well tell people that there's never any reason to waste time on scene with an uncontrolled bleeder, and if they're delaying transport to fiddle with things like IVs then they're generally wrong to do that. Now if we say they should give TXA, well... now they have a reason to stay and play.
I dunno. Unintended consequences.
I dunno. Unintended consequences.
I agree. If you're suggesting that there's probably subgroups buried in the data that are less likely to benefit from TXA, or more likely to be harmed, even when given < 3 hours, and that there may be groups that have greater benefit, including at time points greater than 3 hours, then I also agree. We just haven't identified those subgroups yet, it doesn't mean that they don't exist.
Well, CRASH-2 was a huge multi-center trial, that showed a clear benefit in a fairly heterogenous group. It could certainly be argued that this group may not resemble a typical EMS population, or that the physicians that enrolled these patients might have been less likely to enroll patients that weren't suffering from traumatic hemorrhage than a group of paramedics.
If you look at the citations in my earlier post, one of them shows benefit in a civilian population in a cohort study design (Cole et al.), and one looks at the CRASH-2 data by risk stratification (Roberts et al.).
I'm not sure what's been published from the prehospital arena, and should probably take a look. I'm just a paramedic who likes to read research, but it seems reasonable that this mortality benefit should transfer. It would be reassuring to see this demonstrated in an RCT environment.
I agree that it's a bad idea to delay transport to give TXA. If we're close to a trauma center, it's unlikely to get done in the ambulance. If we're further out, then it will get done en route, or while rendez-vous'ing with the helicopter. Ultimately if people are poorly trained and ill-disciplined enough to delay transport for anything other than hemorrhage control or critical airway management then there's bigger issues than adding TXA.