Luke R Johnston, MD1, Carlos J Rodriguez, DO1, Eric Elster1, Matthew J Bradley, MD2. 1Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD, 2Naval Medical Research Center, Silver Spring, MD
Objectives: Since the publication of the CRASH 2 and MATTERs studies, inclusion of tranexamic acid (TXA) has become the standard of care in massive transfusion protocols (MTP). Concordantly, its application in military combat has expanded with the update to the Joint Theater Trauma System Clinical Practice Guidelines (JTTSCPG), which recommended TXA administration in causalities likely to require massive transfusion. We review the military’s use of TXA and evaluate the appropriateness of its administration in combat trauma.
Methods: We performed a retrospective study of all patients injured in theater and ultimately evacuated to a single military treatment facility within the continental United States from 2011-2015. Data collected for all patients included receipt of blood products, TXA and/or a massive transfusion (MT), and admission hemodynamics. Errors were defined as omission errors where patients received a MT and did not receive TXA, commission errors where TXA was administered in a hemodynamically stable patient who did not receive a MT, or late errors when TXA was administered greater than three hours after injury. Complications were reviewed.
Results: Of the 455 patients identified, 173 received an MT (average of 36.6 units, median 26 units) and 139 patients received TXA in theater. Explosions (65%) followed by gunshot wounds (24%) were the most common mechanisms of injury. 92.1% (n=128/139) of patients received TXA appropriately. Omission errors occurred in 26.6% (n=46/173) of patients who received a MT. Commission errors were found in 7.9% (n=11/139) of TXA administrations. Late errors occurred in 4.3% (n=6/139) of TXA administrations. There were no differences in presentation vital signs or injury severity scores, in omission or commission error groups and appropriate TXA groups. Omission errors as a percentage of total TXA administrations decreased over time (-3.6% per quarter, p=.011), and commission errors increased over time (3.3% per quarter, p=0.04), and overall proportion of appropriate administrations did not change over time (p=0.33). 50% (n=3/6) of patients in the late error group and 18% (n=2/11) of patients in the commission errors group had thromboembolic complications.
Conclusions: The administration of TXA to treat combat casualties with severe hemorrhage has become and remains an important component of MTP. Our evidence demonstrates that while there is an encouraging decrease in missed opportunities to reduce mortality from hemorrhage with TXA administration, this is matched by an increase in inappropriate administration and further study of the risks and benefits of TXA use in combat trauma is warranted.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 78747
Program Number: MSS18
Presentation Session: Full-Day Military Surgical Symposium – Trauma/Critical Care Presentations
Presentation Type: MSSPodium