Department of Emergency Medicine, UC Davis School of Medicine, Sacramento, CA.
Faculty of Health, Queensland University of Technology, Translational Research Institute, Brisbane, QLD, Australia.
Acad Emerg Med. 2020 May;27(5):358-365. doi: 10.1111/acem.13883. Epub 2020 Mar 19.
The CRASH-2 trial demonstrated that tranexamic acid (TXA) in adults with significant traumatic hemorrhage safely reduces mortality. Given that the CRASH-2 trial did not include U.S. sites, our objective was to evaluate patient characteristics, TXA dosing strategies, and the incidence of mortality and adverse events in adult trauma patients receiving TXA at a U.S. Level I trauma center in the post-CRASH-2 era.
We conducted a retrospective study that included patients aged 18 years or older who received TXA after an acute injury from July 2014 to June 2017. We excluded patients who received TXA orally, patients who received TXA for elective surgical procedures or nontrauma indications, patients who received it 8 hours or longer after the time of injury, and patients with cardiac arrest at time of emergency department arrival. Trained abstractors collected data from the trauma registry and hospital electronic medical records. Our primary outcome measures were in-hospital death and acute thromboembolic events within 28 days from injury.
We included 273 patients with a mean (±SD) age of 43.8 (±18.7) years. The mean (±SD) time of administration of TXA from time of injury was 1.55 (±1.2) hours with 229 patients (83.9%) receiving TXA within 3 hours. The overall mortality within 28 days from injury was 12.8% (95% confidence interval [CI] = 8.9% to 16.7%), which was similar compared to that in the CRASH-2 trial (14.5%, 95% CI = 13.9% to 15.2%). The incidence of acute thromboembolic events was 6.6% (95% CI = 3.7% to 9.5%), which was higher than that in the CRASH-2 trial (2.0%, 95% CI = 1.73% to 2.27%). Patients in our cohort also received surgery (64.8% vs. 47.9%) and blood transfusions (74.0% vs. 50.4%) more frequently than those in the CRASH-2 cohort.
Adult trauma patients receiving TXA had similar incidences of death but higher incidences of thromboembolic events compared to the CRASH-2 trial. Variation in patient characteristics, injury severity, TXA dosing, and surgery and transfusion rates could explain these observed differences. Further research is necessary to provide additional insight into the incidence and risk factors of thromboembolic events in TXA use.
CRASH-2 试验表明，氨甲环酸（TXA）可安全降低成人严重创伤性出血患者的死亡率。鉴于 CRASH-2 试验未包括美国的试验点，我们的目的是评估在美国一级创伤中心接受 TXA 的成年创伤患者的患者特征、TXA 给药方案以及死亡率和不良事件的发生率，这些患者是在 CRASH-2 试验之后接受 TXA 治疗的。
我们进行了一项回顾性研究，纳入了 2014 年 7 月至 2017 年 6 月间因急性损伤而接受 TXA 治疗的年龄在 18 岁或以上的患者。我们排除了经口给予 TXA 的患者、因择期手术或非创伤原因而接受 TXA 治疗的患者、在受伤 8 小时或更久后接受 TXA 治疗的患者以及在急诊科到达时发生心搏骤停的患者。接受过培训的记录员从创伤登记处和医院电子病历中收集数据。我们的主要结局指标是伤后 28 天内的院内死亡和急性血栓栓塞事件。
我们纳入了 273 名平均（±标准差）年龄为 43.8（±18.7）岁的患者。TXA 从受伤时间起的平均（±标准差）给药时间为 1.55（±1.2）小时，有 229 名（83.9%）患者在 3 小时内接受了 TXA。伤后 28 天内的总体死亡率为 12.8%（95%置信区间 [CI]：8.9%至 16.7%），与 CRASH-2 试验中的死亡率（14.5%，95%CI：13.9%至 15.2%）相似。急性血栓栓塞事件的发生率为 6.6%（95%CI：3.7%至 9.5%），高于 CRASH-2 试验中的发生率（2.0%，95%CI：1.73%至 2.27%）。我们队列中的患者接受手术（64.8%比 47.9%）和输血（74.0%比 50.4%）的频率也高于 CRASH-2 队列中的患者。
与 CRASH-2 试验相比，接受 TXA 治疗的成年创伤患者的死亡率相似，但血栓栓塞事件的发生率更高。患者特征、损伤严重程度、TXA 剂量、手术和输血率的差异可能解释了这些观察到的差异。需要进一步的研究来提供更多关于 TXA 使用中血栓栓塞事件的发生率和危险因素的信息。
