This week, we are highlighting a Cochrane summary on blood clot promoting drugs for children with acute traumatic injury.
This is an update of an existing Cochrane review, the last version was published in 2012.
Injury is the second leading cause of death for people aged five to 45 years. Over four million people worldwide die of injuries every year, often because of extensive blood loss. Antifibrinolytic drugs promote blood clotting by preventing blood clots from breaking down. Some examples of antifibrinolytic drugs are aprotinin, tranexamic acid (TXA), epsilon-aminocaproic acid and aminomethylbenzoic acid. Doctors sometimes give these drugs to patients having surgery to prevent blood loss. These drugs might also stop blood loss in seriously injured patients and, as a result, save lives.
The authors of this review searched for randomised trials assessing the effects of antifibrinolytics in trauma patients.
The evidence in this review is current to January 2015.
We found three randomised trials which met inclusion criteria and included well data from over 20,000 patients recruited in 40 countries.
Of these, one small trial (n = 77) looked at the effect of aprotinin in patients aged 12 and older who had suffered trauma involving broken bones and shock.
Two trials assessed the effect of TXA in patients aged 16 and over. The largest (n = 20,211) involved patients suffering from a variety of types of trauma, and the other (n = 240) only those who had suffered traumatic brain injury.
The trial assessing the effect of aprotinin was too small to provide reliable data.
Results for TXA suggest that, when given early, TXA reduces the risk of death compared to patients who do not receive TXA without increasing the risk of side effects.
However, there is still some uncertainty about the effect of TXA in patients who have bleeding inside the brain from a head injury, but are not bleeding from injuries elsewhere. It is possible that the effects of TXA are different in this specific patient group.
We have found two ongoing trials that are trying to answer this question.
The authors of this review conclude that TXA can safely reduce death in trauma patients with bleeding and should be given as soon as possible after injury. However, they cannot conclude whether or not TXA is also effective in patients with traumatic brain injury with no other trauma, until the ongoing trials have been completed.
Quality of the evidence
Evidence for important outcomes including mortality, need for further surgery and blood transfusion, came from high-quality evidence, meaning we have confidence in the findings. There was moderate-quality evidence for important adverse events including vascular occlusive events (including heart attacks, deep vein thrombosis, stroke and pulmonary embolism).
TXA safely reduces mortality in trauma patients with bleeding without increasing the risk of adverse events. TXA should be given as early as possible and within three hours of injury, as further analysis of the CRASH-2 trial showed that treatment later than this is unlikely to be effective and may be harmful. Although there is some promising evidence for the effect of TXA in patients with TBI, substantial uncertainty remains.
Two ongoing trials being conducted in patients with isolated TBI should resolve these remaining uncertainties.
Check out the full Cochrane systematic review below:
Ker, K., Roberts, I., Shakur, H., & Coats, T. J. (2015). Antifibrinolytic drugs for acute traumatic injury. Cochrane Database Syst Rev, 5, Cd004896. doi: 10.1002/14651858.CD004896.pub4
Related TREKK Resources:
This post is part of a weekly blog series highlighting pediatric emergency medicine (PEM) focused Cochrane summaries and other key resources selected by TREKK.
Published by arrangement with John Wiley & Sons.