Efficacy and safety of tranexamic acid in acute traumatic brain injury: a systematic review and meta-analysis of randomized-controlled trials.

PURPOSE: With the publication of a large randomized-controlled trial (RCT) suggesting that tranexamic acid (TXA) may improve head-injury-related deaths, we aimed to determine the safety and efficacy of TXA in acute traumatic brain injury (TBI). METHODS: In this systematic review and meta-analysis, we searched MEDLINE, PubMed, EMBASE, CINHAL, ACPJC, Google Scholar, and unpublished sources from inception until June 24, 2020 for randomized-controlled trials comparing TXA and placebo in adults and adolescents (≥ 15 years of age) with acute TBI. We screened studies and extracted summary estimates independently and in duplicate. We assessed the quality of evidence using the grading of recommendations assessment, development, and evaluation approach. This study is registered with PROSPERO (CRD42020164232). RESULTS: Nine RCTs enrolled 14,747 patients. Compared to placebo, TXA had no effect on mortality (RR 0.95; 95% CI 0.88-1.02; RD 1.0% reduction; 95% CI 2.5% reduction to 0.4% increase, moderate certainty) or disability assessed by the Disability Rating Scale (MD, - 0.18 points; 95% CI - 0.43 to 0.08; moderate certainty). TXA may reduce hematoma expansion on subsequent imaging (RR 0.77; 95% CI 0.58-1.03, RD 3.6%, 95% CI 6.6% reduction to 0.5% increase, low certainty). Risks of adverse events (all moderate, low, or very low certainty) were similar between placebo and TXA. CONCLUSIONS: In patients with acute TBI, TXA probably has no effect on mortality or disability. TXA may decrease hematoma expansion on subsequent imaging; however, this outcome is likely of less importance to patients. The use of TXA probably does not increase the risk of adverse events.

The end of early-goal directed therapy?

Emergency medicine practitioners around the world have been confronted with the increasing challenge of managing patients in severe sepsis and septic shock. Introduction of early goal-directed therapy (EGDT) revolutionized sepsis care and was adopted worldwide. Since then, multiple randomized controlled trials have been published questioning the superiority of EGDT. The purpose of this article is to review and provide clinical commentary on the ProCESS, ARISE, and ProMISE trials, which address whether invasive, expensive interventions are needed to achieve mortality reduction goals in septic patients. This article discusses that EGDT bundled care is not necessary to achieve mortality reduction goals.

Outcomes of emergency department thoracotomy in a tertiary care Canadian trauma centre.

OBJECTIVE: Emergency department thoracotomy (EDT) is a rare and potentially life-saving intervention performed for trauma patients in extremis. EDT is rare at Canadian trauma centres because of our infrequent occurrence of penetrating trauma. This study was undertaken to evaluate outcomes at a Canadian level 1 trauma facility and compare survival to large published datasets. Also, we evaluated the appropriateness of an EDT performed at our centre based on published national guidelines. METHODS: Retrospective medical record review of all patients undergoing an EDT during their resuscitation in the emergency department. Records were identified using our trauma registry, and all charts were manually reviewed. The primary outcome was survival to hospital discharge. RESULTS: Over a 20-year period, 58 EDTs were performed with 6 (10.3%) survivors. Patients undergoing an EDT secondary to penetrating trauma had the highest survival (5 of 24 patients or 20.8% survival) compared to patients undergoing an EDT for blunt trauma (1 of 34 patients or 2.9% survival). Patients undergoing an EDT who had not suffered cardiac arrest represented the group with the highest survival rate (3 of 6 patients or 50% survival). The majority of EDTs (79.3%) were indicated, and no patient undergoing an EDT survived if it was performed outside of published guidelines. CONCLUSIONS: Survival following an EDT in our small, regional trauma centre is consistent with survival rates from larger published datasets. An EDT should continue to be performed under accepted clinical indications.