Question: With the recent training surrounding hemorrhage control will we potentially see TXA administration added to our medical directives? Also wondering if you see pelvic binding brought into our skill set in the future?
There has been some discussion at the provincial MAC about the addition of Tranexamic Acid (TXA) to the ALS PCS to be used to control massive hemorrhage and continues to be considered as more evidence is generated. There is debate about its indications, how often it would be used in the Ontario setting, various protocols for its use, and concerns over its cost. The Crash-2 study, the largest study to support the use of TXA, in civilian settings, was based on administration of the drug in the Emergency Department (1). It demonstrated that TXA reduces mortality by about 10% measured at four weeks in hospital, with most of the effect achieved if you get the drug within three hours of being injured. So trying to show a 10% mortality benefit in 20 minutes of urban EMS contact time becomes a theoretical 1% benefit, and that is without all of the extra treatment challenges in an already very busy prehospital case, where we are also advocating not to stay on scene to start an IV. The Crash-2 study required twenty thousand cases to show an effect, and most trauma occurs in urban centres with fast transport times. There could be more theoretical value with long transport times or more geographically isolated situations, which is why most modern militaries are utilizing it in the prehospital environment for combat injuries, however there are not many cases worldwide, and treatment details are not standardized for studying.
There may be parts of Ontario where this could be theoretically beneficial and TXA utilized, and unlikely that there will be a large enough trial to show benefit. A smaller, more recent, cohort study of prehospital administered TXA did not show any overall mortality benefit (2). Crash-3 is currently looking at benefits with TXA in traumatic brain injury, and perhaps this will show an effect for prehospital care in the future.
You raised a concern regarding pelvic binding not being within the paramedic scope of practice, however it currently does exist.
The BLS Blunt and Penetrating Injury Standard (BLS Standards v 3.0.1) located on page 95 states:
3. if the patient has a pelvic fracture,
a. attempt to stabilize the clinically unstable pelvis with a circumferential sheet wrap or a commercial device,
b. secure the patient to a spinal board or adjustable break-away stretcher,
c. avoid placing spinal immobilization or stretcher straps directly over the pelvic area, and
d. secure and immobilize lower limbs to prevent additional pelvic injury.
Pelvic binding to control bleeding in pelvic fractures has some theoretical appeal, and it is certainly not a packaging device but a treatment device (3). The evidence for its effectiveness is mostly anecdotal. There are many challenges in applying this in the prehospital setting. Pelvic fractures are not as readily evident as external hemorrhage. None of the devices have been validated for prehospital situations, and are really based on cadaveric testing, with next to skin land marking, as we do in ER with patient fully exposed.
1. Roberts I1, Shakur H, Coats T, Hunt B, Balogun E, Barnetson L, Cook L, Kawahara T, Perel P, Prieto-Merino D, Ramos M, Cairns J, Guerriero C. The CRASH-2 trial: a randomised controlled trial and economic evaluation of the effects of tranexamic acid on death, vascular occlusive events and transfusion requirement in bleeding trauma patients. Health Technol Assess. 2013 Mar;17(10):1-79. doi: 10.3310/hta17100.
2. Wafaisade A1, Lefering R2, Bouillon B3, BÃ¶hmer AB4, GÃ¤ÃŸler M5, Ruppert M5; TraumaRegister DGU., Prehospital administration of tranexamic acid in trauma patients. Crit Care. 2016 May 12;20(1):143. doi: 10.1186/s13054-016-1322-5.
3. Scott, Porter, Laird, Greaves Bloch The prehospital management of pelvic binders: initial consensus statement, Emerg Med J Dec 2013, Vol 30, No 12 1070-1072.