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Ho MP. Traumatic brain injury: Role of tranexamic acid. Am J Emerg Med 2024; 83:131. [PMID: 38760185 DOI: 10.1016/j.ajem.2024.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 05/08/2024] [Indexed: 05/19/2024] Open
Affiliation(s)
- Min-Po Ho
- Department of Emergency Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan.
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Vrettou CS, Dima E, Karela NR, Sigala I, Korfias S. Severe Traumatic Brain Injury and Pulmonary Embolism: Risks, Prevention, Diagnosis and Management. J Clin Med 2024; 13:4527. [PMID: 39124793 PMCID: PMC11313609 DOI: 10.3390/jcm13154527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2024] [Revised: 07/21/2024] [Accepted: 07/29/2024] [Indexed: 08/12/2024] Open
Abstract
Severe traumatic brain injury (sTBI) is a silent epidemic, causing approximately 300,000 intensive care unit (ICU) admissions annually, with a 30% mortality rate. Despite worldwide efforts to optimize the management of patients and improve outcomes, the level of evidence for the treatment of these patients remains low. The concomitant occurrence of thromboembolic events, particularly pulmonary embolism (PE), remains a challenge for intensivists due to the risks of anticoagulation to the injured brain. We performed a literature review on sTBI and concomitant PE to identify and report the most recent advances on this topic. We searched PubMed and Scopus for papers published in the last five years that included the terms "pulmonary embolism" and "traumatic brain injury" in their title or abstract. Exclusion criteria were papers referring to children, non-sTBI populations, and post-acute care. Our search revealed 75 papers, of which 38 are included in this review. The main topics covered include the prevalence of and risk factors for pulmonary embolism, the challenges of timely diagnosis in the ICU, the timing of pharmacological prophylaxis, and the treatment of diagnosed PE.
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Affiliation(s)
- Charikleia S. Vrettou
- First Department of Critical Care Medicine, Evangelismos Hospital, Medical School, National & Kapodistrian University of Athens, 10676 Athens, Greece (N.R.K.)
| | - Effrosyni Dima
- First Department of Critical Care Medicine, Evangelismos Hospital, Medical School, National & Kapodistrian University of Athens, 10676 Athens, Greece (N.R.K.)
| | - Nina Rafailia Karela
- First Department of Critical Care Medicine, Evangelismos Hospital, Medical School, National & Kapodistrian University of Athens, 10676 Athens, Greece (N.R.K.)
| | - Ioanna Sigala
- First Department of Critical Care Medicine, Evangelismos Hospital, Medical School, National & Kapodistrian University of Athens, 10676 Athens, Greece (N.R.K.)
| | - Stefanos Korfias
- Department of Neurosurgery, Evaggelismos General Hospital of Athens, 10676 Athens, Greece
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Sarhan RM, Boshra MS, Abdelrahim MEA, Osama H. Tranexamic acid in patients with traumatic brain injury: a meta-analysis. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024; 71:360-367. [PMID: 38387502 DOI: 10.1016/j.redare.2024.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 02/08/2023] [Accepted: 04/13/2023] [Indexed: 02/24/2024]
Abstract
BACKGROUND We performed a meta-analysis to assess the effectiveness and safety of tranexamic acid in patients with traumatic brain injury (TBI). METHODS We searched the literature for articles evaluating the effectiveness and safety of tranexamic acid (TXA) in TBI published between January 2012 and January 2021, and identified 8 studies with a total of 10860 patients: 5660 received TXA and 5200 served as controls. We used a dichotomous or continuous approach with a random or fixed-effect model to assess the efficacy and safety of TXA in TBI, and calculated the mean difference (MD) and odds ratio (OR) with the corresponding 95% confidence interval. RESULTS In patients with TBI, early administration of TXA was associated with a greater relative benefit (MD -2.45; 95% CI = -4.78 to -0.12; p=0.04) and less total haematoma expansion (MD - 2.52; 95% CI = -4.85 to -0.19; p=0.03) compared to controls. There were no statistically significant differences in mortality (OR 0.94; 95% CI=0.85-1.03; p=0.18), presence of progressive haemorrhage (OR 0.75; 95% CI=0.56-1.01; p=0.06), need for neurosurgery (OR 1.15; 95% CI=0.66-1.98; p=0.63), high Disability Rating Scale score (OR 0.90; 95% CI=0.56-1.45; p=0.68), and incidence of ischaemic or thromboembolic complications (OR 1.34; 95% CI=0.33-5.46; p=0.68) between TBI patients treated with TXA and controls. CONCLUSIONS Early administration of TXA in TBI patients may have a greater relative benefit and may inhibit haematoma expansion. There were no significant differences in mortality, presence of progressive haemorrhage, need for neurosurgery, high Disability Rating Scale score, and incidence of ischaemic or thromboembolic complications between TBI patients treated with TXA and controls. Further studies are needed to validate these results.
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Affiliation(s)
- R M Sarhan
- Departamento de Farmacia Clínica, Facultad de Farmacia, Universidad Beni-Suef, Beni-Suef, Egypt
| | - M S Boshra
- Departamento de Farmacia Clínica, Facultad de Farmacia, Universidad Beni-Suef, Beni-Suef, Egypt
| | - M E A Abdelrahim
- Departamento de Farmacia Clínica, Facultad de Farmacia, Universidad Beni-Suef, Beni-Suef, Egypt.
| | - H Osama
- Departamento de Farmacia Clínica, Facultad de Farmacia, Universidad Beni-Suef, Beni-Suef, Egypt
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Javeed SS, Altawili MA, Almubarak LNA, Alaodah SA, Alqarni MMA, Odeh OI, Asiri MAB, Alotaibi RAM, Alshammari AAA, Alqutayfi ZAM, Altemani OSD, Al Gharban DAM, Zafar ZA. The Effectiveness of Prehospital Administration of Tranexamic Acid in Reducing Mortality in Trauma Patients: An Overview. Cureus 2023; 15:e49784. [PMID: 38161561 PMCID: PMC10757764 DOI: 10.7759/cureus.49784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2023] [Indexed: 01/03/2024] Open
Abstract
Tranexamic acid (TXA) is an antifibrinolytic drug that reduces bleeding by inhibiting plasminogen activation and fibrin clot degradation. Its role in prehospital trauma management remains unclear. This article aims to systematically review the current evidence on the effect of prehospital TXA administration on mortality in adult and pediatric trauma patients. A literature search was conducted of PubMed, Web of Science, Scopus, and Cochrane databases from March 2023 to August 2023 for studies evaluating the impact of prehospital TXA use on trauma mortality. Inclusion criteria were articles published in the English language in the past 20 years focusing on clinical outcomes of prehospital TXA administration. Data on all-cause mortality, thromboembolic events, and time to TXA administration were extracted. In adult trauma, prehospital TXA appears to reduce early all-cause mortality when given within three hours of injury without increasing thromboembolic risks. Some studies found decreased delayed mortality, while others found no difference. In pediatric trauma, preliminary evidence suggests TXA may lower in-hospital mortality in hemodynamically unstable patients, though higher doses may increase seizure risk. Early prehospital administration of TXA within three hours of adult trauma may reduce mortality through improved hemorrhage control. Potential benefits in pediatric trauma warrant further investigation, balancing efficacy against safety risks such as seizures from high doses. Well-designed randomized trials are needed to validate optimal TXA dosing strategies across age groups and injury severity levels.
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Affiliation(s)
- Syed S Javeed
- Emergency Medicine, King Salman Armed Forces Hospital, Tabuk, SAU
| | | | | | | | | | - Omar I Odeh
- Medical School, King Saud University College of Medicine, Riyadh, SAU
| | | | | | | | | | | | | | - Zohair A Zafar
- General Practice, Al-Awali Primary Health Care Center, Makkah, SAU
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5
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Tranexamic acid for traumatic brain injury. Am J Emerg Med 2023; 63:151. [PMID: 36153260 DOI: 10.1016/j.ajem.2022.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 09/14/2022] [Indexed: 12/13/2022] Open
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Biffi A, Porcu G, Castellini G, Napoletano A, Coclite D, D’Angelo D, Fauci AJ, Iacorossi L, Latina R, Salomone K, Iannone P, Gianola S, Chiara O, Medici A, Mazzola A, Coniglio C, De Blasio E, Flego G, Geraci M, Maccauro G, Rampoldi A, Santolini F, Tacconi C, Tugnoli G, Stocchetti N, Fabbri A, Ruggeri MP, Seta MD, Pizzarelli S, Cammarano RR. Systemic hemostatic agents initiated in trauma patients in the pre-hospital setting: a systematic review. Eur J Trauma Emerg Surg 2022; 49:1259-1270. [DOI: 10.1007/s00068-022-02185-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 11/24/2022] [Indexed: 12/23/2022]
Abstract
Abstract
Purpose
The effect of systemic hemostatic agents initiated during pre-hospital care of severely injured patients with ongoing bleeding or traumatic brain injury (TBI) remains controversial. A systematic review and meta-analysis was therefore conducted to assess the effectiveness and safety of systemic hemostatic agents as an adjunctive therapy in people with major trauma and hemorrhage or TBI in the context of developing the Italian National Institute of Health guidelines on major trauma integrated management.
Methods
PubMed, Embase, and Cochrane Library databases were searched up to October 2021 for studies that investigated pre-hospital initiated treatment with systemic hemostatic agents. The certainty of evidence was evaluated with the Grading of Recommendations Assessment, Development, and Evaluation approach, and the quality of each study was determined with the Cochrane risk-of-bias tool. The primary outcome was overall mortality, and secondary outcomes included cause-specific mortality, health-related quality of life, any adverse effects and blood product use, hemorrhage expansion, and patient-reported outcomes.
Results
Five trials of tranexamic acid (TXA) met the inclusion criteria for this meta-analysis. With a high certainty of evidence, when compared to placebo TXA reduced mortality at 24 h (relative risk = 0.83, 95% confidence interval = 0.73–0.94) and at 1 month among trauma patients (0.91, 0.85–0.97). These results depend on the subgroup of patients with significant hemorrhage because in the subgroup of TBI there are no difference between TXA and placebo. TXA also reduced bleeding death and multiple organ failure whereas no difference in health-related quality of life.
Conclusion
Balancing benefits and harms, TXA initiated in the pre-hospital setting can be used for patients experiencing major trauma with significant hemorrhage since it reduces the risk of mortality at 24 h and one month with no difference in terms of adverse effects when compared to placebo. Considering the subgroup of severe TBI, no difference in mortality rate was found at 24 h and one month. These results highlight the need to conduct future studies to investigate the role of other systemic hemostatic agents in the pre-hospital settings.
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Antifibrinolytics in the treatment of traumatic brain injury. Curr Opin Anaesthesiol 2022; 35:583-592. [PMID: 35900731 PMCID: PMC9594127 DOI: 10.1097/aco.0000000000001171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE OF REVIEW Traumatic brain injury (TBI) is a leading cause of trauma-related deaths, and pharmacologic interventions to limit intracranial bleeding should improve outcomes. Tranexamic acid reduces mortality in injured patients with major systemic bleeding, but the effects of antifibrinolytic drugs on outcomes after TBI are less clear. We therefore summarize recent evidence to guide clinicians on when (not) to use antifibrinolytic drugs in TBI patients. RECENT FINDINGS Tranexamic acid is the only antifibrinolytic drug that has been studied in patients with TBI. Several recent studies failed to conclusively demonstrate a benefit on survival or neurologic outcome. A large trial with more than 12 000 patients found no significant effect of tranexamic acid on head-injury related death, all-cause mortality or disability across the overall study population, but observed benefit in patients with mild to moderate TBI. Observational evidence signals potential harm in patients with isolated severe TBI. SUMMARY Given that the effect of tranexamic acid likely depends on a variety of factors, it is unlikely that a 'one size fits all' approach of administering antifibrinolytics to all patients will be helpful. Tranexamic acid should be strongly considered in patients with mild to moderate TBI and should be avoided in isolated severe TBI.
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8
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Tranexamic acid – A narrative review for the emergency medicine clinician. Am J Emerg Med 2022; 56:33-44. [DOI: 10.1016/j.ajem.2022.03.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 03/07/2022] [Accepted: 03/14/2022] [Indexed: 02/06/2023] Open
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Karl V, Thorn S, Mathes T, Hess S, Maegele M. Association of Tranexamic Acid Administration With Mortality and Thromboembolic Events in Patients With Traumatic Injury: A Systematic Review and Meta-analysis. JAMA Netw Open 2022; 5:e220625. [PMID: 35230436 PMCID: PMC8889461 DOI: 10.1001/jamanetworkopen.2022.0625] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
IMPORTANCE Tranexamic acid is widely available and used off-label in patients with bleeding traumatic injury, although the literature does not consistently agree on its efficacy and safety. OBJECTIVE To examine the association of tranexamic acid administration with mortality and thromboembolic events compared with no treatment or with placebo in patients with traumatic injury in the literature. DATA SOURCES On March 23, 2021, PubMed, Embase, and the Cochrane Library were searched for eligible studies published between 1986 and 2021. STUDY SELECTION Randomized clinical trials and observational studies investigating tranexamic acid administration compared with no treatment or placebo among patients with traumatic injury and traumatic brain injury who were 15 years or older were included. Included studies were published in English or German. The electronic search yielded 1546 records, of which 71 were considered for full-text screening. The selection process was performed independently by 2 reviewers. DATA EXTRACTION AND SYNTHESIS The study followed the Cochrane Handbook for Systematic Reviews of Interventions and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data were extracted by 2 independent reviewers and pooled using the inverse-variance random-effects model. MAIN OUTCOMES AND MEASURES Outcomes were formulated before data collection and included mortality at 24 hours and 28 and 30 days (1 month) as well as the incidence of thromboembolic events and the amount of blood products administered. Owing to missing data, overall mortality was added and the amount of blood products administered was discarded. RESULTS Thirty-one studies with a total of 43 473 patients were included in the systematic review. The meta-analysis demonstrated that administration of tranexamic acid was associated with a significant decrease in 1-month mortality compared with the control cohort (risk ratio, 0.83 [95% CI, 0.71-0.97]; I2 = 35%). The results of meta-analyses for 24-hour and overall mortality and thromboembolic events were heterogeneous and could not be pooled. Further investigations on clinical heterogeneity showed that populations with trauma and trial conditions differed markedly. CONCLUSIONS AND RELEVANCE These findings suggest that tranexamic acid may be beneficial in various patient populations with trauma. However, reasonable concerns about potential thromboembolic events with tranexamic acid remain.
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Affiliation(s)
- Vivien Karl
- Institute for Research in Operative Medicine, Faculty of Health, Department of Medicine, Witten/Herdecke University, Cologne, Germany
| | - Sophie Thorn
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Emergency Medicine, Alfred Health, Melbourne, Australia
| | - Tim Mathes
- Institute for Research in Operative Medicine, Faculty of Health, Department of Medicine, Witten/Herdecke University, Cologne, Germany
- Institute for Medical Statistics, University Medical Centre, Göttingen, Germany
| | - Simone Hess
- Institute for Research in Operative Medicine, Faculty of Health, Department of Medicine, Witten/Herdecke University, Cologne, Germany
| | - Marc Maegele
- Institute for Research in Operative Medicine, Faculty of Health, Department of Medicine, Witten/Herdecke University, Cologne, Germany
- Department of Traumatology, Orthopaedic Surgery and Sports Traumatology, Cologne-Merheim Medical Centre, Witten/Herdecke University, Campus Cologne-Merheim, Cologne, Germany
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10
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Kovalev V, Dong F, Bagheri S, Wong D, Wi M. Effectiveness of Tranexamic Acid in Reducing Hemorrhage in Isolated Blunt Solid Organ Injury. Cureus 2021; 13:e20473. [PMID: 35070532 PMCID: PMC8761172 DOI: 10.7759/cureus.20473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2021] [Indexed: 11/05/2022] Open
Abstract
Introduction: There is considerable interest in the use of tranexamic acid (TXA) for the control of hemorrhages in trauma patients. Multiple recent studies found that TXA used in the setting of a suspected significant hemorrhage in trauma patients significantly reduced mortality. To date, there are no cited studies that specifically address hemorrhage due to solid organ injury (i.e., kidneys, liver, and spleen) and TXA use in humans. Our current research addresses whether TXA is effective in reducing complications and mortality from traumatic hemorrhage in the setting of a specific solid organ injury. Methods: We conducted a retrospective observational cohort study utilizing propensity score matching at Arrowhead Regional Medical Center (ARMC) from February 1, 2009 to February 1, 2019. This study period marks five years prior to and five years after February 1, 2004, which is the date when TXA first started to be used at ARMC in the management of traumatic hemorrhage. We compared for statistical difference between corresponding injury types in the TXA and non-TXA groups. Results: Before the propensity matching, there were 123 patients who received TXA and 118 patients who did not. After propensity match for age and injury severity score (ISS), 35 patients were included in each group. We found no statistically significant difference between TXA and non-TXA treatment groups in terms of mortality at 24 hours (p-value=0.4945), mortality at 48 hours (p-value=0.4945), and mortality at 28 days (p-value=0.7426). We found no statistically significant difference between the need for interventional radiology intervention at 72 hours (p-value=0.3932), surgical intervention at 72 hours (p-value=0.2123) and possible TXA related complications (p-value=1). Conclusion: Although prior studies showed that TXA use in the setting of trauma may be beneficial, the specific candidate-selection criteria remain unclear. The results of our study suggest that the benefit from TXA in the setting of the isolated splenic, liver, and or renal injury may be negligible. We believe that this first-of-its-kind study adds to the growing body of knowledge about the utility of TXA and helps guide patient-selection criteria.
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The Effects of Intraoperative Local Tranexamic Acid on Periorbital Edema and Ecchymosis in Septorhinoplasty. J Craniofac Surg 2021; 32:e526-e530. [PMID: 33534311 DOI: 10.1097/scs.0000000000007493] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION The aim of the present study is to examine the effect of local administration of tranexamic acid (TXA) through lateral osteotomy line on postoperative periorbital edema and ecchymosis. MATERIALMETHOD Thirty patients underwent open technical septorhinoplasty were included. Before lateral osteotomies, the surgeon opened narrow subperiosteal tunnels on the both sides. After lateral osteotomies, the surgeon irrigated TXA into the right tunnel with the broken tip of the injection and the same amount of saline into the left tunnel. The patient's photographs were taken on the first, third, and seventh postoperative days. Periorbital edema and ecchymoses were evaluated by the blinded author. The statistical differences between the 2 sides were analyzed. RESULTS Lower Eyelid Edema values were significantly lower in the TXA(+) group than the TXA(-) group on the third day (P = 0.001). There was no statistically significant difference between the sides in terms of lower eyelid edema values on the first and seventh days (P = 0.065, P = 0.317). Upper and lower eyelid ecchymosis values were significantly lower in TXA(+) group than TXA(-) group on the first, third, and seventh days (P < 0.05). Upper eyelid edema values were found to be significantly lower in the TXA(+) group than the TXA(-) group on the first and third days (P = 0.002, P = 0.005). There was no statistically significant between the sides in terms of upper eyelid edema (P = 0.315) on the seventh day. CONCLUSIONS It was observed in the present study that local administration of TXA in septorhinoplasty was effective in reducing postoperative periorbital edema and ecchymosis.Level of evidence: 2c.
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12
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Bleeding Disorders in Primary Fibrinolysis. Int J Mol Sci 2021; 22:ijms22137027. [PMID: 34209949 PMCID: PMC8268566 DOI: 10.3390/ijms22137027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 06/07/2021] [Accepted: 06/18/2021] [Indexed: 11/24/2022] Open
Abstract
Fibrinolysis is a complex enzymatic process aimed at dissolving blood clots to prevent vascular occlusions. The fibrinolytic system is composed of a number of cofactors that, by regulating fibrin degradation, maintain the hemostatic balance. A dysregulation of fibrinolysis is associated with various pathological processes that result, depending on the type of abnormality, in prothrombotic or hemorrhagic states. This narrative review is focused on the congenital and acquired disorders of primary fibrinolysis in both adults and children characterized by a hyperfibrinolytic state with a bleeding phenotype.
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Anderson TN, Farrell DH, Rowell SE. Fibrinolysis in Traumatic Brain Injury: Diagnosis, Management, and Clinical Considerations. Semin Thromb Hemost 2021; 47:527-537. [PMID: 33878779 DOI: 10.1055/s-0041-1722970] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Posttraumatic coagulopathy involves disruption of both the coagulation and fibrinolytic pathways secondary to tissue damage, hypotension, and inflammatory upregulation. This phenomenon contributes to delayed complications after traumatic brain injury (TBI), including intracranial hemorrhage progression and systemic disseminated intravascular coagulopathy. Development of an early hyperfibrinolytic state may result in uncontrolled bleeding and is associated with increased mortality in patients with TBI. Although fibrinolytic assays are not routinely performed in the assessment of posttraumatic coagulopathy, circulating biomarkers such as D-dimer and fibrin degradation products have demonstrated potential utility in outcome prediction. Unfortunately, the relatively delayed nature of these tests limits their clinical utility. In contrast, viscoelastic tests are able to provide a rapid global assessment of coagulopathy, although their ability to reliably identify disruptions in the fibrinolytic cascade remains unclear. Limited evidence supports the use of hypertonic saline, cryoprecipitate, and plasma to correct fibrinolytic disruption; however, some studies suggest more harm than benefit. Recently, early use of tranexamic acid in patients with TBI and confirmed hyperfibrinolysis has been proposed as a strategy to further improve clinical outcomes. Moving forward, further delineation of TBI phenotypes and the clinical implications of fibrinolysis based on phenotypic variation is needed. In this review, we summarize the clinical aspects of fibrinolysis in TBI, including diagnosis, treatment, and clinical correlates, with identification of targeted areas for future research efforts.
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Affiliation(s)
- Taylor N Anderson
- School of Medicine, Division of Trauma, Critical Care and Acute Care Surgery, Oregon Health and Science University, Portland, Oregon
| | - David H Farrell
- School of Medicine, Division of Trauma, Critical Care and Acute Care Surgery, Oregon Health and Science University, Portland, Oregon
| | - Susan E Rowell
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
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Takahashi CE, Virmani D, Chung DY, Ong C, Cervantes-Arslanian AM. Blunt and Penetrating Severe Traumatic Brain Injury. Neurol Clin 2021; 39:443-469. [PMID: 33896528 DOI: 10.1016/j.ncl.2021.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
Severe traumatic brain injury is a common problem. Current practices focus on the importance of early resuscitation, transfer to high-volume centers, and provider expertise across multiple specialties. In the emergency department, patients should receive urgent intracranial imaging and consideration for tranexamic acid. Close observation in the intensive care unit environment helps identify problems, such as seizure, intracranial pressure crisis, and injury progression. In addition to traditional neurologic examination, patients benefit from use of intracranial monitors. Monitors gather physiologic data on intracranial and cerebral perfusion pressures to help guide therapy. Brain tissue oxygenation monitoring and cerebromicrodialysis show promise in studies.
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Affiliation(s)
- Courtney E Takahashi
- Department of Neurology, Boston Medical Center, 72 East Concord Street, Collamore, C-3, Boston, MA 02118, USA.
| | - Deepti Virmani
- Department of Neurology, Boston University School of Medicine and Boston Medical Center, 72 East Concord Street, Collamore, C-3, Boston, MA 02118, USA
| | - David Y Chung
- Department of Neurology, Boston University School of Medicine and Boston Medical Center, 72 East Concord Street, Collamore, C-3, Boston, MA 02118, USA; Division of Neurocritical Care, Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA; Neurovascular Research Unit, Department of Radiology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Charlene Ong
- Department of Neurology, Boston University School of Medicine and Boston Medical Center, 72 East Concord Street, Collamore, C-3, Boston, MA 02118, USA
| | - Anna M Cervantes-Arslanian
- Boston University School of Medicine and Boston Medical Center, 72 East Concord Street, Collamore, C-3, Boston, MA 02118, USA
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15
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Fu R, Liu C, Yan Y, Suo L, Xie Y, Li Q, Huang RL. Tranexamic Acid in Craniomaxillofacial Surgery: A Meta-Analysis and Systematic Review. Facial Plast Surg Aesthet Med 2021; 23:422-429. [PMID: 33661026 DOI: 10.1089/fpsam.2020.0590] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Objective: To compare the effectiveness of tranexamic acid (TXA) in reducing blood loss and decreasing surgery duration in craniomaxillofacial surgery. Methods: The literature was searched systematically for all comparative studies of the effect of TXA on craniomaxillofacial surgery with placebo to evaluate the efficacy of TXA in craniomaxillofacial surgery. The primary outcome was intraoperative blood loss, and secondary outcomes were postoperative hematocrit, postoperative hemoglobin, and operation duration. Results: This systematic review included 16 studies consisting of 958 patients. Meta-analysis revealed that compared with the placebo group, the TXA group showed a significant reduction in intraoperative blood loss of 139.81 mL (95% confidence interval, CI: -179.66 to -99.96 mL; p < 0.01), a shortening of the maxillary surgery duration of 15.48 min (95% CI: -21.03 to -9.92 min; p < 0.01), an elevation of the postoperative hemoglobin level of 0.74 mg/dL (95% CI: 0.42 to 1.07 mg/dL; p < 0.01), and a limited effect on increasing the postoperative hematocrit level of 1.77% (95% CI: 0.17 to 3.36; p = 0.03). Conclusion: The use of TXA in craniomaxillofacial surgery can effectively reduce intraoperative blood loss, maintain elevate postoperative hemoglobin and hematocrit levels, and reduce the operation duration.
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Affiliation(s)
- Rao Fu
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chuanqi Liu
- Department of Plastic and Burn Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yuxin Yan
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Linlang Suo
- Department of Surgery, Shanghai Eighth People's Hospital, Shanghai, China
| | - Yun Xie
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qingfeng Li
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ru-Lin Huang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Efficacy and safety of tranexamic acid in acute traumatic brain injury: a systematic review and meta-analysis of randomized-controlled trials. Intensive Care Med 2020; 47:14-27. [PMID: 33079217 DOI: 10.1007/s00134-020-06279-w] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 10/05/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE With the publication of a large randomized-controlled trial (RCT) suggesting that tranexamic acid (TXA) may improve head-injury-related deaths, we aimed to determine the safety and efficacy of TXA in acute traumatic brain injury (TBI). METHODS In this systematic review and meta-analysis, we searched MEDLINE, PubMed, EMBASE, CINHAL, ACPJC, Google Scholar, and unpublished sources from inception until June 24, 2020 for randomized-controlled trials comparing TXA and placebo in adults and adolescents (≥ 15 years of age) with acute TBI. We screened studies and extracted summary estimates independently and in duplicate. We assessed the quality of evidence using the grading of recommendations assessment, development, and evaluation approach. This study is registered with PROSPERO (CRD42020164232). RESULTS Nine RCTs enrolled 14,747 patients. Compared to placebo, TXA had no effect on mortality (RR 0.95; 95% CI 0.88-1.02; RD 1.0% reduction; 95% CI 2.5% reduction to 0.4% increase, moderate certainty) or disability assessed by the Disability Rating Scale (MD, - 0.18 points; 95% CI - 0.43 to 0.08; moderate certainty). TXA may reduce hematoma expansion on subsequent imaging (RR 0.77; 95% CI 0.58-1.03, RD 3.6%, 95% CI 6.6% reduction to 0.5% increase, low certainty). Risks of adverse events (all moderate, low, or very low certainty) were similar between placebo and TXA. CONCLUSIONS In patients with acute TBI, TXA probably has no effect on mortality or disability. TXA may decrease hematoma expansion on subsequent imaging; however, this outcome is likely of less importance to patients. The use of TXA probably does not increase the risk of adverse events.
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Lee PL, Yang KS, Tsai HW, Hou SK, Kang YN, Chang CC. Tranexamic acid for gastrointestinal bleeding: A systematic review with meta-analysis of randomized clinical trials. Am J Emerg Med 2020; 45:269-279. [PMID: 33041136 DOI: 10.1016/j.ajem.2020.08.062] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 08/19/2020] [Accepted: 08/20/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Acute gastrointestinal bleeding is a common life-threatening emergent condition. Immediate tranexamic acid is useful for reducing hemorrhage following operation and bleeding trauma, but evidence on the effects of tranexamic acid in patients with gastrointestinal bleeding is limited or highly heterogeneous. It is still unclear about using tranexamic acid in the emergent condition of gastrointestinal bleeding. This study, therefore, aimed to determine whether or not tranexamic acid should be used in gastrointestinal bleeding management through systematic review and meta-analysis. METHODS We searched three biomedical databases for relevant randomized controlled trials on this topic. Two authors independently selected studies and extracted data for bias assessment and meta-analysis of bleeding, further intervention, mortality, transfusion, and intensive care unit admission. Available data were pooled using a random-effects model, and the results were presented as risk ratios (RRs) with 95% confidence intervals (CIs). Heterogeneity and small study effects were also assessed. RESULTS Thirteen randomized controlled trials (n = 2271) were included in the present synthesis. Our meta-analysis revealed that tranexamic acid significantly reduced the rates of continued bleeding (RR = 0.60; 95%CI, 0.43-0.84), urgent endoscopic intervention (RR = 0.35; 95%CI, 0.24-0.50), and mortality (RR = 0.60; 95%CI, 0.45-0.80) compared with the placebo. CONCLUSION According to the available evidence, the present synthesis confirms that tranexamic acid is an effective medication for patients with upper gastrointestinal bleeding. Early administration of tranexamic acid may be worth to be recommended for treating upper gastrointestinal bleeding in the emergency department. However, the effects of tranexamic acid on lower gastrointestinal bleeding warrant further clarification.
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Affiliation(s)
- Po-Lin Lee
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Kai-Suan Yang
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Hong-Wei Tsai
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Sen-Kuang Hou
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Yi-No Kang
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei, Taiwan; Evidence-Based Medicine Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; Research Center of Big Data and Meta-Analysis Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; Institute of Health Policy & Management, College of Public Health, Taipei, Taiwan.
| | - Chun-Chao Chang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan; Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Medicine, Taipei Medical University, Taipei, Taiwan.
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18
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Du CN, Liu BX, Ma QF, Yang MF. The effect of tranexamic acid in patients with TBI: a systematic review and meta-analysis of randomized controlled trials. Chin Neurosurg J 2020; 6:14. [PMID: 32922943 PMCID: PMC7398208 DOI: 10.1186/s41016-020-00196-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 04/15/2020] [Indexed: 01/26/2023] Open
Abstract
To conduct a systematic review and meta-analysis and evaluate the effect of tranexamic acid in patients with traumatic brain injury. PubMed, EMBASE, and CENTRAL (Cochrane Central Register of Controlled Trials) were searched to identify randomized controlled trials and evaluate the effect of tranexamic acid in traumatic brain injury patients. The primary outcome was mortality. Two reviewers extracted the data independently. The random effect meta-analysis was used to estimate the aggregate effect size of 95% confidence intervals. Six randomized controlled trials investigating tranexamic acid versus placebo and 30073 patients were included. Compared with placebo, tranexamic acid decreased the mortality (RR = 0.92; 95% CI, 0.87-0.96; p < 0.001) and growth of hemorrhagic mass (RR = 0.78; 95% CI, 0.61-0.99; p = 0.04). However, tranexamic acid could not decrease disability or independent, neurosurgery, vascular embolism, and stroke. Current evidence suggested that compared with placebo, tranexamic acid could reduce mortality and growth of hemorrhagic mass. This finding indicated that patients with traumatic brain injury should be treated with tranexamic acid.
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Affiliation(s)
- Chao-Nan Du
- Graduate School, Qinghai University, Xining, Qinghai China
| | - Bo-Xue Liu
- Graduate School, Qinghai University, Xining, Qinghai China
| | - Qing-Fang Ma
- Department of Neurosurgery, Xuzhou Central Hospital, Xuzhou, Jiangsu China
| | - Ming-Fei Yang
- Department of Neurosurgery, Qinghai Provincial People's Hospital, Xining, Qinghai China
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19
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The efficacy of tranexamic acid for brain injury. Am J Emerg Med 2020; 45:562. [PMID: 32747162 DOI: 10.1016/j.ajem.2020.07.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 07/20/2020] [Indexed: 11/21/2022] Open
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20
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Evangelista ME, Gaffley M, Neff LP. Massive Transfusion Protocols for Pediatric Patients: Current Perspectives. J Blood Med 2020; 11:163-172. [PMID: 32547282 PMCID: PMC7247594 DOI: 10.2147/jbm.s205132] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 04/24/2020] [Indexed: 01/03/2023] Open
Abstract
In adults, the use of balanced resuscitation and study of massive transfusion protocols have led to improved outcomes for patients and continues to be refined. In children, massive transfusion protocols require further development and study to assess efficacy. Standardization is needed as transfusions and activation of protocols still rely on physician discretion in most pediatric settings. Further research is required to define the pediatric trauma population that will benefit, when to activate these protocols and how to use adjuncts such as tranexamic acid or factor VII in resuscitation. In addition, future implementation of technology such as hemoglobin-based oxygen carriers to increase survival should be studied further in this subset of patients.
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Affiliation(s)
| | - Michaela Gaffley
- General Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Lucas P Neff
- Pediatric Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
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21
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Franchini M, Mannucci PM. The never ending success story of tranexamic acid in acquired bleeding. Haematologica 2020; 105:1201-1205. [PMID: 32336684 PMCID: PMC7193503 DOI: 10.3324/haematol.2020.250720] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 03/16/2020] [Indexed: 12/13/2022] Open
Abstract
Tranexamic acid (TXA) is an anti-fibrinolytic agent that acts by inhibiting plasminogen activation and fibrinolysis. Although its first clinical use dates back more than 50 years, this hemostatic agent is still the object of intense clinical and developmental research. In particular, renewed interest in TXA has arisen following evidence that it has a beneficial effect in reducing blood loss in a variety of medical and surgical conditions at increased risk of bleeding. Given this characteristic, TXA is currently considered a mainstay of Patient Blood Management programs aimed at reducing patients’ exposure to allogeneic blood transfusion. Importantly, recent large randomized controlled trials have consistently documented that the use of TXA confers a survival advantage in a number of globally critical clinical conditions associated with acute bleeding, including traumatic injury and post-partum hemorrhage, without increasing the thromboembolic risk.
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Affiliation(s)
- Massimo Franchini
- Department of Transfusion Medicine and Hematology, Carlo Poma Hospital, Mantova
| | - Pier Mannuccio Mannucci
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
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Claret PG, Jadeau M, Palacin-Ballarin T, Burel M, Danard L, de Poret F. Actualités en médecine d’urgence. ANNALES FRANCAISES DE MEDECINE D URGENCE 2020. [DOI: 10.3166/afmu-2020-0228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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