Survival benefit of prehospital TXA in fibrinolytic shutdown: Insights from two prospective trauma trials
In brief
Prehospital TXA linked to two-thirds lower death hazard in shutdown patients
In a combined analysis of 1,249 trauma patients, those with fibrinolytic shutdown who were randomized to prehospital tranexamic acid had about two-thirds lower adjusted hazard of death than those not given the drug. Shutdown patients overall had 14.5% 30-day mortality, but this trial subanalysis cannot settle who benefits; larger studies are needed to guide early treatment.
- Journal
- The journal of trauma and acute care surgery (Q1)
- Published
- 9 October 2026
- Study design
- Randomized controlled trial
- Evidence level
- Level 1, High (CEBM 1b)
- Authors
- James E Kenny, Alexandra Mp Brito, Myriam Benchiba-Charron, Nicholas Larson, Ella Chrenka, Biswadev Mitra, et al.
- PMID
- 42853261
- DOI
- 10.1097/TA.0000000000005092
Why clinicians should know about it
- Picked for Emergency Medicine (top studies of the week, 11 October 2026): Prehospital TXA improves trauma survival, ED relevance
- Picked for Surgery (paper of the day, 10 October 2026): Prehospital TXA benefit in trauma phenotypes
Abstract
BACKGROUND: Fibrinolytic phenotypes have been implicated in postinjury pathophysiology and outcomes. While prehospital tranexamic acid (TXA) administration has demonstrated survival benefits, the interaction between TXA administration and distinct fibrinolytic profiles remains poorly defined. METHODS: We analyzed data from a harmonized dataset combining 2 prospective trials evaluating prehospital TXA use in trauma (Prehospital Tranexamic Acid Use for Traumatic Brain Injury and the Study of Tranexamic Acid During Air and Ground Medical Prehospital Transport Trial). Patients were stratified by initial thromboelastographic (TEG) LY30 into fibrinolytic shutdown (<0.9%), hyperfibrinolysis (>3%), and physiological fibrinolysis (0.9-3%). The primary outcome was 30-day mortality. Secondary outcomes included 24-hour mortality and adverse events. Multivariable regression adjusted for TXA administration, fibrinolysis phenotypes, age, mechanism of injury, injury severity score, and shock index on presentation to the hospital. RESULTS: Among 1,249 patients, 30-day mortality was 14.5% in the fibrinolytic shutdown group, 6.7% in the hyperfibrinolysis group, and 6.5% in the physiological fibrinolysis group. After multivariable regression, hyperfibrinolysis was associated with increased risk of death (HR 2.87; 95% CI: 1.10-7.53; p 0.03). Patients with fibrinolytic shutdown who were randomized to TXA had decreased risk of death (HR 0.32; 95% CI: 0.11-0.91; p=0.03). CONCLUSIONS: This multitrial analysis revealed greater statistically significant differences between fibrinolytic phenotypes than analysis of each trial alone. Fibrinolytic phenotypes were independently associated with mortality. Fibrinolytic shutdown in patients randomized to receive TXA was associated with lower risk of death. These findings support the relevance of fibrinolysis profiling during early trauma care and underscore the need for larger studies to further elucidate the prognostic and therapeutic implications in trauma. LEVEL OF EVIDENCE: II (Subanalysis of Randomized Controlled Trials).
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.