Research is needed to determine how patient selection and intercurrent treatment affect safety and efficacy
Clinicians involved in the resuscitation of severely injured patients face a dilemma. On one hand, since publication of the landmark CRASH-2 (Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage 2) study in 2010,1 there has been an international push for inclusion of tranexamic acid (TxA) in trauma management protocols. On the other hand, the need for more evidence to solve ongoing knowledge gaps has been emphasised, especially evidence of who benefits and whether anyone is harmed when TxA is administered to patients treated to modern civilian and military trauma standards.2,3 While both views represent well intentioned efforts to improve care, they create conflicting priorities that must be reconciled before patients can properly benefit.
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- 2. Pusateri AE, Weiskopf RB, Bebarta V, et al. Tranexamic acid and trauma: current status and knowledge gaps with recommended research priorities. Shock 2013; 39: 121-126.
- 3. Napolitano LM, Cohen MJ, Cotton BA, et al. Tranexamic acid in trauma: how should we use it? J Trauma Acute Care Surg 2013; 74: 1575-1586.
- 4. Ker K, Edwards P, Perel P, et al. Effect of tranexamic acid on surgical bleeding: systematic review and cumulative meta-analysis. BMJ 2012; 344: e3054.
- 5. Roberts I, Shakur H, Afolabi A, et al. The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomised controlled trial. Lancet 2011; 377: 1096-1101.e1-2.
- 6. Shakur H, Roberts I, Piot P, et al. A promise to save 100 000 trauma patients. Lancet 2012; 380: 2062-2063.
- 7. Gruen RL, Mitra B. Tranexamic acid for trauma. Lancet 2011; 377: 1052-1054.
- 8. Morrison JJ, Dubose JJ, Rasmussen TE, Midwinter MJ. Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study. Arch Surg 2012; 147: 113-119.
- 9. Mitra B, Cameron PA, Gruen RL. Aggressive fresh frozen plasma (FFP) with massive blood transfusion in the absence of acute traumatic coagulopathy. Injury 2012; 43: 33-37.
- 10. Ioannidis JP. Contradicted and initially stronger effects in highly cited clinical research. JAMA 2005; 294: 218-228.
- 11. Goldberger JJ, Buxton AE. Personalized medicine vs guideline-based medicine. JAMA 2013; 309: 2559-2560.
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