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- Title
Effect of Out-of-Hospital Tranexamic Acid vs Placebo on 6-Month Functional Neurologic Outcomes in Patients With Moderate or Severe Traumatic Brain Injury.
- Authors
Rowell, Susan E.; Meier, Eric N.; McKnight, Barbara; Kannas, Delores; May, Susanne; Sheehan, Kellie; Bulger, Eileen M.; Idris, Ahamed H.; Christenson, Jim; Morrison, Laurie J.; Frascone, Ralph J.; Bosarge, Patrick L.; Colella, M. Riccardo; Johannigman, Jay; Cotton, Bryan A.; Callum, Jeannie; McMullan, Jason; Dries, David J.; Tibbs, Brian; Richmond, Neal J.
- Abstract
<bold>Importance: </bold>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.<bold>Objective: </bold>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.<bold>Design, Setting, and Participants: </bold>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.<bold>Interventions: </bold>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).<bold>Main Outcomes and Measures: </bold>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.<bold>Results: </bold>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).<bold>Conclusions and Relevance: </bold>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.<bold>Trial Registration: </bold>ClinicalTrials.gov Identifier: NCT01990768.
- Subjects
TRANEXAMIC acid; BRAIN injury treatment; BRAIN injuries; PLACEBOS; NEUROLOGY; RESEARCH; BRAIN diseases; INTRAVENOUS therapy; CLINICAL trials; CLASSIFICATION; RESEARCH methodology; MEDICAL care; PATIENTS; EVALUATION research; MEDICAL cooperation; NEUROPSYCHOLOGICAL tests; COMPARATIVE studies; RANDOMIZED controlled trials; BLIND experiment; SURVIVAL analysis (Biometry); EMERGENCY medical services; GLASGOW Coma Scale; RESEARCH funding; ANTIFIBRINOLYTIC agents; LONGITUDINAL method
- Publication
JAMA: Journal of the American Medical Association, 2020, Vol 324, Issue 10, p961
- ISSN
0098-7484
- Publication type
journal article
- DOI
10.1001/jama.2020.8958