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CRASH-3 Trial

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The Primary Exam
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The CRASH-3 Trial has been published.

CRASH-2 demonstrated that early administration of tranexamic acid(within 3 hours of injury) reduced bleeding deaths by one third(1). In CRASH-3, the investigators looked at the effects of tranexamic acid in patients with potential traumatic brain injury.

The Trial

International, multi-centre, randomised, placebo-controlled trial

Big Trial

Eligibility criteria:

  • Within 3 hours of injury
  • GCS <12 or intracranial bleed on CT scan and
  • No major extra cranial bleed

Primary Outcome: Head injury-related death in the hospital within 28 days in patients treated within 3 hours.

n = 4613 patient assigned to tranexamic acid and 4514 assigned to placebo.

Results/Comments:

  • There was a reduction in head-injury related deaths in patients with mild(GCS of 13-15)-moderate head injury(RR 0.78 [95%CI 0.64-0.95]) when given within 3 hours of injury- these are large confidence intervals
  • We need to remember that the sickest patients ie., the GCS 3, fixed dilated pupils were removed from this study.
  • No clear evidence of reduction in death in those with severe injury (0.99[0.91-1.07])
  • No evidence of adverse effects or complications, although the risk of deep venous thrombosis or pulmonary embolism was not captured in the study.
  • Dose of tranexamic acid used was:
    • loading dose of 1g over 10 minutes followed by
    • IV infusion of 1g over 8 hours

My Take

  • It’s safe
  • It may result in decreased mortality in a particular subgroup: but not statistically significant
  • It’s a discussion to have with the team as the results are not as compelling as CRASH 2.
  • The real result will probably be that patients will get it as they will be getting it for their other trauma, regardless
  • However for isolated intracranial trauma………..I’ll probably give it, if within 3 hours. But I’ll have a discussion with my surgeons well in advance, so we have a protocol.

What will you do?

References

The CRASH-2 Collaborators. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placeboocntrolled trial. Lancet 2010;376:23-32

Dr Peter Kas

Emergency Physician, Educator. Key Interests: Resuscitation, Airway, Emergency Cardiology, Clinical Examination. Creator resus.com.au.

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