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Original Investigation
September 8, 2020

Effect of Out-of-Hospital Tranexamic Acid vs Placebo on 6-Month Functional Neurologic Outcomes in Patients With Moderate or Severe Traumatic Brain Injury

Author Affiliations
  • 1Department of Surgery, Oregon Health & Science University, Portland
  • 2Department of Surgery, Duke University School of Medicine, Durham, North Carolina
  • 3Department of Biostatistics, University of Washington, Seattle
  • 4Department of Surgery, University of Washington, Seattle
  • 5Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas
  • 6Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
  • 7Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
  • 8Providence Health Care Research Institute, Vancouver, British Columbia, Canada
  • 9Rescu, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
  • 10Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
  • 11Department of Emergency Medicine, Regions Hospital, St Paul, Minnesota
  • 12Department of Surgery, University of Alabama, Birmingham
  • 13Department of Surgery, University of Arizona, Phoenix
  • 14Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee
  • 15Department of Surgery, University of Cincinnati, Cincinnati, Ohio
  • 16Department of Surgery, McGovern Medical School, University of Texas Health Science Center, Houston
  • 17Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, Ontario, Canada
  • 18Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio
  • 19Department of Surgery, Regions Hospital, St Paul, Minnesota
  • 20Trauma Surgery, Texas Health Presbyterian Hospital, Dallas
  • 21Department of Emergency Medicine, John Peter Smith Health Network, Ft Worth, Texas
  • 22Johns Hopkins School of Medicine, Baltimore, Maryland
  • 23British Columbia Emergency Health Services, Vancouver, British Columbia, Canada
  • 24Department of Emergency Medicine, Baylor University Medical Center, Dallas, Texas
  • 25Department of Surgery, Mayo Clinic, Rochester, Minnesota
  • 26Department of Surgery, John Peter Smith Health Network, Ft Worth, Texas
  • 27Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
  • 28Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
  • 29Department of Surgery, St Michael’s Hospital, Toronto, Ontario, Canada
  • 30Department of Emergency Medicine, Medical City Plano, Plano, Texas
  • 31Emergency Medicine, Methodist Dallas Medical Center, Dallas, Texas
  • 32National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
  • 33Trauma Surgery, Texas Health Harris Methodist Hospital, Ft Worth
JAMA. 2020;324(10):961-974. doi:10.1001/jama.2020.8958
Key Points

Question  Does early administration of tranexamic acid to patients with moderate or severe traumatic brain injury improve neurologic outcome at 6 months?

Findings  In this randomized multicenter clinical trial that included 966 participants enrolled in the out-of-hospital setting by paramedics, treatment with tranexamic acid as an out-of-hospital bolus with or without in-hospital infusion, compared with placebo as an out-of-hospital bolus and in-hospital infusion, resulted in a favorable neurologic outcome (defined as Glasgow Outcome Scale-Extended score >4) in 65% vs 62% of patients at 6 months, a difference that was not statistically significant.

Meaning  Among participants suspected of having moderate or severe traumatic brain injury, out-of-hospital administration of tranexamic acid compared with placebo did not significantly improve 6-month neurologic recovery.

Abstract

Importance  Traumatic brain injury (TBI) is the leading cause of death and disability due to trauma. Early administration of tranexamic acid may benefit patients with TBI.

Objective  To determine whether tranexamic acid treatment initiated in the out-of-hospital setting within 2 hours of injury improves neurologic outcome in patients with moderate or severe TBI.

Design, Setting, and Participants  Multicenter, double-blinded, randomized clinical trial at 20 trauma centers and 39 emergency medical services agencies in the US and Canada from May 2015 to November 2017. Eligible participants (N = 1280) included out-of-hospital patients with TBI aged 15 years or older with Glasgow Coma Scale score of 12 or less and systolic blood pressure of 90 mm Hg or higher.

Interventions  Three interventions were evaluated, with treatment initiated within 2 hours of TBI: out-of-hospital tranexamic acid (1 g) bolus and in-hospital tranexamic acid (1 g) 8-hour infusion (bolus maintenance group; n = 312), out-of-hospital tranexamic acid (2 g) bolus and in-hospital placebo 8-hour infusion (bolus only group; n = 345), and out-of-hospital placebo bolus and in-hospital placebo 8-hour infusion (placebo group; n = 309).

Main Outcomes and Measures  The primary outcome was favorable neurologic function at 6 months (Glasgow Outcome Scale-Extended score >4 [moderate disability or good recovery]) in the combined tranexamic acid group vs the placebo group. Asymmetric significance thresholds were set at 0.1 for benefit and 0.025 for harm. There were 18 secondary end points, of which 5 are reported in this article: 28-day mortality, 6-month Disability Rating Scale score (range, 0 [no disability] to 30 [death]), progression of intracranial hemorrhage, incidence of seizures, and incidence of thromboembolic events.

Results  Among 1063 participants, a study drug was not administered to 96 randomized participants and 1 participant was excluded, resulting in 966 participants in the analysis population (mean age, 42 years; 255 [74%] male participants; mean Glasgow Coma Scale score, 8). Of these participants, 819 (84.8%) were available for primary outcome analysis at 6-month follow-up. The primary outcome occurred in 65% of patients in the tranexamic acid groups vs 62% in the placebo group (difference, 3.5%; [90% 1-sided confidence limit for benefit, −0.9%]; P = .16; [97.5% 1-sided confidence limit for harm, 10.2%]; P = .84). There was no statistically significant difference in 28-day mortality between the tranexamic acid groups vs the placebo group (14% vs 17%; difference, −2.9% [95% CI, −7.9% to 2.1%]; P = .26), 6-month Disability Rating Scale score (6.8 vs 7.6; difference, −0.9 [95% CI, −2.5 to 0.7]; P = .29), or progression of intracranial hemorrhage (16% vs 20%; difference, −5.4% [95% CI, −12.8% to 2.1%]; P = .16).

Conclusions and Relevance  Among patients with moderate to severe TBI, out-of-hospital tranexamic acid administration within 2 hours of injury compared with placebo did not significantly improve 6-month neurologic outcome as measured by the Glasgow Outcome Scale-Extended.

Trial Registration  ClinicalTrials.gov Identifier: NCT01990768

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