I have read the link in the study provided for TXA.
I did not listen to the podcast.
I remain skeptical about the potential benefits of TXA.
In my ongoing bid to determine if trauma treatment can be used to help improve outcome in ruptured aneurysm, i reviewed multiple articles of case reports on the use of txa and aprotinin.
In all of the literature, from text books, to clinical trials, to case reports, it is relatively unanimous that these substances only show a benefit it the most complex or severe patient populations in both thoracic and abd aneurysm populations.
These situations were often defined as significant comorbities or massive transfusion requirement.
Massive transfusion is also considered an independant risk factor and predictor of mortality in almost all of them.
Aprotinin particularly was shown to benefit in these patient populations. With less renal complications than txa.
Most of the supporting evidence for medical therapies to trauma like txa and factor VII come from military trials.
Civillian centers often report benefit in a much smaller population.
Some of the things to consider:
The military sees a much higher incidence of severe penetrating trauma than the civillian world. Which leads to the conclusion that the population which may actually benefit from these medical interventions prior to surgery may be minimal.
There is also the issue that civillian trauma centers do not maintain the volume and therefore experience in this high level of penetrating trauma, which will degrade the effective identification and desire to use these agents.
An Military/EMS style protocol is not useful in critical medicine, the patients are simply too variable, with chronic comorbidities, extremes of age, general health status, etc.
Civilians are not rigorous preselected healthy people.
While the latest I have read shows trauma is on the increase, blunt trauma in the civillian world (particularly motor vehicle accidents) are still more common than penetrating.
These are not conducive to therapies for penetrating trauma. (if they were, survival rates and techniques would be the same)
There are also limitations to the study in terms of criteria.
Civillian studies on the subject of TXA (and the like) do not find a link or prognostic ability between them and mortality or long term disability. Again they defer to the need of massive transfusion as the independant predictor.
We then must consider the aggression of surgical correction in the civillian world compared to the military. Damage control surgery, while obviously beneficial from all military accounts is not the common standard of care outside of the military.
In fact most surgeons I have spoken with on the matter indicate not only do they not use it, they do not consider it. Citing complications in infection, ICU and surgical resources, and even the inability to maintain patients in the resuscitation/follow-up surgery cycle.
When you compare the trauma system of the military to the civillian world, it is more than a reversal of numbers of levels of care.
In civillian centers there may be 1 trauma/critical care surgeon on duty in a given center. Not a team of them through escalating care. I doubt you will find level III centers who will do temporizing measures like vascular grafts and send these patients on to the level I. According to the ATLS guidlines, as soon as they recognize the patient is of significant severity, minimal intervention prior to transport is the norm and the goal.
Medical resuscitation without surgical intervention in a patient requiring surgery is just delaying the needed care.
A facility not providing temporizing surgery is basically just delaying the patient from somebody who will.
In modern surgery there is also a push to exclude surgical intervention except in cases where it will most likely be successful. That is a far cry from the military idea of "do what you can." or "anything is better than nothing." (there are many factors that create the civillian environment, the 2 biggest I see is the culture of surgeons and money.)
Those are not easily correctable.
So aside from the actual medical benefit/complications of these agents, the system culture and logistics also make these interventions unlikely to succeed.
Regretably, while many places have the trauma center designation, many simply take a conservative approach to trauma.
With the focus on minimally invasive surgery, the opportunity and therefore comfort and proficency with emergent open surgery is decreasing. As this continues, so will the selectivity of the surgeons.
For these reasons, I do not see the current military advances in trauma transitioning to the civillian world.
