Out-of-Hospital Tranexamic Acid Is Recommended for Trauma Patients in Emergencies

We read with interest a meta-analysis in the Annals of Emergency Medicine in November 2023 (online ahead of print). 1 Fouche P.F. Stein C. Nichols M. et al. Tranexamic acid for traumatic injury in the emergency setting: a systematic review and bias-adjusted meta-analysis of randomized controlled trials. Ann Emerg Med. 2024; 83: 435-445 Abstract Full Text Full Text PDF Scopus (1) Google Scholar The article indicates that the out-of-hospital use of tranexamic acid (TXA) in emergency trauma situations is associated with a reduction in 1-month mortality without significant evidence of adverse vascular occlusive events. Although the meta-analysis appropriately separates out-of-hospital TXA use from inhospital settings, concerns arise due to practical heterogeneity among studies. The STAAMP trial and a trial by Rowell et al highlight distinctions in TXA use, particularly between out-of-hospital bolus (TXA-B) and the combination of out-of-hospital bolus and inhospital maintenance (TXA-BM). 2 Guyette F.X. Brown J.B. Zenati M.S. et al. Tranexamic acid during prehospital transport in patients at risk for hemorrhage after injury: a double-blind, placebo-controlled, randomized clinical trial. JAMA Surg. 2020; 156: 11-20 PubMed Google Scholar ,3 Rowell S.E. Meier E.N. McKnight B. et al. Effect of out-of-hospital tranexamic acid vs placebo on 6-month functional neurologic outcomes in patients with moderate or severe traumatic brain injury. JAMA. 2020; 324: 961-974 Crossref PubMed Scopus (161) Google Scholar The recent PATCH-Trauma trial exclusively investigated out-of-hospital TXA-BM. 4 Gruen R.L. Mitra B. Bernard S.A. et al. Prehospital tranexamic acid for severe trauma. N Engl J Med. 2023; 389: 127-136 Crossref Scopus (38) Google Scholar These randomized controlled trials show some inconsistencies in the risk of mortality. Given these variations, a network meta-analysis would be a better method to test the effects of different TXA protocols on mortality. This letter aimed to test differences in 1-month mortality among TXA-B, TXA-BM, and placebo using a consistency model. In replyAnnals of Emergency MedicineVol. 83Issue 6PreviewWe express our gratitude to the reader for their engagement with our systematic review and meta-analysis focusing on tranexamic acid (TXA) in trauma within emergency settings. The differences in out-of-hospital TXA treatments across the PATCH, Guyette et al,1 and Rowell et al2 studies are acknowledged. Each trial used a unique TXA approach: some arms of these trials had only an immediate bolus, others combined an immediate bolus with a slow infusion, and all trials included a placebo arm.1-3 The observed differences in TXA treatment approaches indicate that a network meta-analysis might be an appropriate method for comparing the 3 distinct treatment options. Full-Text PDF