Tranexamic acid in polish pre-hospital emergency medicine and the competencies of medical rescue teams
Abstract
INTRODUCTION: Medical rescue teams (MRTs) are the basic components of the Polish Emergency Medicine System (PEMS) that provide pre-hospital emergency medical services. However, despite the possibility for paramedics to use 47 drugs and many complicated medical procedures, tranexamic acid was not found there. Efficacy of pre-hospital emergency medical services could be improved by using tranexamic acid (TXA) in the management of traumatic hemorrhage and traumatic brain injury (TBI). The aim of this study was to demonstrate that the competencies of MRTs should be expanded and that Polish paramedics should be authorized to independently administer TXA to TBI patients.
MATERIAL AND METHODS: The main research method was an analysis of the literature, including studies focusing on TXA administration and the associated risks. The article was written in the last two years.
RESULTS: The study demonstrated that TXA contributes to the effective management of selected types of hemorrhage and TBI and that the risk of adverse effects associated with TXA administration is minimal.
CONCLUSIONS: The gathered evidence suggests that paramedics should be authorized to independently administer TXA in pre-hospital care to maximize the efficacy of emergency medical services provided to patients in the PEMS.
Keywords: tranexamic acidhemorrhagesystemambulance
References
- WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled triall. Lancet. 2017; 389(10084): 2105–2116.
- Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 2010; 376(9734): 23–32.
- The CRASH-3 Trial Collaborators. Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH-3): a randomised, placebo-controlled trial. Lancet. 2019; 394(10210): 1713–1723.
- Morrison JJ, Dubose JJ, Rasmussen TE, et al. Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study. Arch Surg. 2012; 147(2): 113–119.
- HALT-IT Trial Collaborators. Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled triall. Lancet. 2020; 20(395): 1927–1936.
- Stępka A, Podlasin A, Jaskuła J, et al. and Janiszewski W. Staza taktyczna — lokalizacja w ratownictwie cywilnym. Na Ratunek. 2018; 4: 31–34.
- Act of 8 September 2006 on the Polish Emergency Medicine System (Journal of Laws, 2006, No. 191, item 1410). https://oipip.walbrzych.pl/pliki/prawo/ustawa%20o%20ratownictwie.pdf (14.12.2021).
- Pomoc doraźna i ratownictwo medyczne w 2020r. Główny Urząd Statystyczny, 2021. https://stat.gov.pl/files/gfx/portalinformacyjny/pl/defaultaktualnosci/5513/14/5/1/pomoc_dorazna_i_ratownictwo_medyczne_w_2020_roku.pdf (20.12.2021).
- Zdrowie i ochrona zdrowia w 2016 r. Główny Urząd Statystyczny, 2017. https://stat.gov.pl/download/gfx/portalinformacyjny/pl/defaultaktualnosci/5513/1/7/1/zdrowie_i_ochrona_zdrowia_w_2016.pdf (14.12.2021).
- Pomoc doraźna i ratownictwo medyczne w 2017 r. Główny Urząd Statystyczny, 2018. https://stat.gov.pl/download/gfx/portalinformacyjny/pl/defaultaktualnosci/5513/14/2/1/pomoc_dorazna_i_ratownictwo_medyczne_w_2017_r.pdf (14.12.2021).
- Pomoc doraźna i ratownictwo medyczne w 2018 r. Główny Urząd Statystyczny, 2019. https://stat.gov.pl/download/gfx/portalinformacyjny/pl/defaultaktualnosci/5513/14/3/1/pomoc_dorazna_i_ratownictwo_medyczne_w_2018_r.pdf (14.12.2021).
- Pomoc doraźna i ratownictwo medyczne w 2019 r. Główny Urząd Statystyczny, 2020. https://stat.gov.pl/download/gfx/portalinformacyjny/pl/defaultaktualnosci/5513/14/4/1/pomoc_dorazna_i_ratownictwo_medyczne_w_2019_r.pdf (14.12.2021).
- Regulation of the Minister of Health of 16 December 2019 on emergency medical procedures and healthcare services other than emergency medical procedures that can be performed by paramedics (Journal of Laws, 2019, item 2478). https://isap.sejm.gov.pl/isap.nsf/download.xsp/WDU20190002478/O/D20192478.pdf (14.12.2021).
- Franchini M, Mannucci PM. The never ending success story of tranexamic acid in acquired bleeding. Haematologica. 2020; 105(5): 1201–1205.
- Reed R, Woolley T. Uses of tranexamic acid. Continuing Edu Anaesthesia Critical Care & Pain. 2015; 15(1): 32–37.
- Charakterystyka produktu leczniczego Exacyl 100mg/ml, roztwór do wstrzykiwań. https://leki.urpl.gov.pl/files/EXACYL_roztwdowstrzyk_100mgml.pdf (18.12.2021).
- Gayet-Ageron A, Prieto-Merino D, Ker K, et al. Effect of treatment delay on the effectiveness and safety of antifibrinolytics in acute severe haemorrhage: a meta-analysis of individual patient-level data from 40 138 bleeding patients. Lancet. 2018; 391(10116): 125–132.
- Chen H, Chen M. The efficacy of tranexamic acid for brain injury: A meta-analysis of randomized controlled trials. Am J Emerg Med. 2020; 38(2): 364–370.
- Stansfield R, Morris D, Jesulola E. The use of tranexamic acid (TXA) for the management of hemorrhage in trauma patients in the prehospital environment: literature review and descriptive analysis of principal themes. Shock. 2020; 53(3): 277–283.
- Wojskowe centrum kształcenia medycznego. Taktyczna pomoc poszkodowanym na polu walki (TCCC). Wytyczne dla personelu medycznego z 5 listopada 2020 r, 2021. https://wckmed.wp.mil.pl/u/wytyczne_TCCC_2020_wersja_1.0.3_PL_docx.pdf (18.12.2018).
- Woroń J. Błędy w leczeniu przeciwzakrzepowym – czyli 7 grzechów głównych stosowania leków przeciwzakrzepowych, przeciwpłytkowych oraz przeciwkrwotocznych w praktyce lekarskiej. Anestezjologia i Ratownictwo. 2017; 11(2): 211–221.
- Lott C, Truhlář A, Alfonzo A, et al. European resuscitation council guidelines 2021: cardiac arrest in special circumstances. Resuscitation. 2021; 161: 152–219.
- Opieka przedszpitalna nad pacjentem po urazie. Omówienie aktualizacji zaleceń PHTLS 2019, Medycyna Praktyczna, 2019. https://www.mp.pl/ratownictwo/wytyczne/210465,opieka-przedszpitalna-nad-pacjentem-po-urazie-omowienie-aktualizacji-zalecen-phtls-2019 (18.12.2021).
- Guerriero C, Cairns J, Perel P, et al. Cost-effectiveness analysis of administering tranexamic acid to bleeding trauma patients using evidence from the CRASH-2 trial. PLoS One. 2011; 6(5): e18987.
- Roberts I, Yates D, Sandercock P, et al. CRASH trial collaborators. Effect of intravenous corticosteroids on death within 14 days in 10008 adults with clinically significant head injury (MRC CRASH trial): randomised placebo-controlled trial. Lancet. 2004; 364(9442): 1321–1328.
- International Trauma Life Support. Role of TXA in management of traumatic haemorrhage in the field. https://www.itrauma.org/wp-content/uploads/2020/01/Current-Thinking-TXA-Resource-Document-Update-FINAL-November-2019.pdf (14.12.2021).
- AEMT. TCCC Guidelines for Medical Personnel, 2017. https://www.naemt.org/docs/default-source/education-documents/tccc/tccc-updates_092017/tccc-mp-curriculum-1708/00-tccc-mp-guidelines/tccc-guidelines-for-medical-personnel-170131.pdf?sfvrsn=2&fbclid=IwAR2dzFxxY4_l-YwBfzsD0i_iPJBy4fmZ_jO0buCMTtNf2OUVUU2uDMj0O1o (14.12.2021).
- NAEMT. TCCC Guidelines for Medical Personnel, 2018. https://www.naemt.org/docs/default-source/education-documents/tccc/tccc-mp/guidelines/tccc-guidelines-for-medical-personnel-180801.pdf?sfvrsn=13fc892_2&fbclid=IwAR3yCm9arQF-NgkydBEof-p0WqjvmfDIiOkAKIrGwOidZaeh3teJsPJjBLA (18.12.2021).
- Sprigg N, Flaherty K, Appleton J, et al. Tranexamic acid for hyperacute primary IntraCerebral Haemorrhage (TICH-2): an international randomised, placebo-controlled, phase 3 superiority trial. Lancet. 2018; 391(10135): 2107–2115.
- Post R, Germans MR, Tjerkstra MA, et al. Ultra-early tranexamic acid after subarachnoid haemorrhage (ULTRA): a randomised controlled trial. Lancet. 2021; 9(397): 112–118.
- Novikova N, Hofmeyr GJ, Cluver C. Tranexamic acid for preventing postpartum haemorrhage. Cochrane Database Syst Rev. 2015; 16(6): CD007872.
- Alam A, Choi S. Prophylactic use of tranexamic acid for postpartum bleeding outcomes: a systematic review and meta-analysis of randomized controlled trials. Transfus Med Rev. 2015; 29(4): 231–241.
- Ducloy-Bouthors AS, Jude B, Duhamel A, et al. EXADELI Study Group. High-dose tranexamic acid reduces blood loss in postpartum haemorrhage. Crit Care. 2011; 15(2): R117.
- Franchini M, Mengoli C, Cruciani M, et al. Safety and efficacy of tranexamic acid for prevention of obstetric haemorrhage: an updated systematic review and meta-analysis. Blood Transfus. 2018; 16(4): 329–337.
- Wand O, Guber E, Guber A, et al. Inhaled Tranexamic Acid for Hemoptysis Treatment: A Randomized Controlled Trial. Chest. 2018; 154(6): 1379–1384.
- Zahed R, Mousavi Jazayeri MH, Naderi A, et al. Topical tranexamic acid compared with anterior nasal packing for treatment of epistaxis in patients taking antiplatelet drugs: randomized controlled trial. Acad Emerg Med. 2018; 25(3): 261–266.
- Beno S, Ackery AD, Callum J, et al. Tranexamic acid in pediatric trauma: why not? Crit Care. 2014; 18(4): 313.
- Eckert MJ, Wertin TM, Tyner SD, et al. Tranexamic acid administration to pediatric trauma patients in a combat setting: the pediatric trauma and tranexamic acid study (PED-TRAX). J Trauma Acute Care Surg. 2014; 77(6): 852–8; discussion 858.
- Van de Voorde P, Turner NM, Djakow J, et al. European Resuscitation Council Guidelines 2021: Paediatric Life Support. Resuscitation. 2021; 161: 327–387.
- Maconochie IK, Bingham R, Eich C, et al. Paediatric life support section Collaborators. European Resuscitation Council Guidelines for Resuscitation 2015: Section 6. Paediatric life support. Resuscitation. 2015; 95: 223–248.
- Justin Morgenstern, "CRASH 3: TXA is no wonder drug", First10EM blog, October 28, 2019. https://doi.org/10.51684/FIRS.9842 (18.12.2021).
- Justin Morgenstern, "3 misunderstandings about WOMAN (TXA in postpartum hemorrhage)", First10EM blog, October 1, 2019. https://doi.org/10.51684/FIRS.9621rrhage)", First10EM blog, October 1, 2019. Available at https://doi.org/10.51684/FIRS.9621. (18.12.2021).