Tranexamic acid in emergency medicine. An overview of reviews

Tranexamic acid (TXA) is a common haemorrhage control agent in both emergency department (ED) settings and intra-operatively. While efficacy and potential harms are well-studied, there are no overviews of reviews completed on TXA efficacy in the ED setting. We set out to provide an overview of systematic reviews on TXA efficacy in trauma, gastrointestinal bleeding, and subarachnoid haemorrhage in the ED setting, with outcomes including short and long-term mortality, thromboembolic (TE) events, and whether bleeding continued. Our review is guided by the PRIOR statement. We searched Pubmed, Medline, and EMBASE using broad search terms for systematic reviews, and calculated pooled relative-risk ratios using random and fixed-effects modelling from these studies. A risk-of-bias assessment was also completed for each review. We identified 13 systematic reviews for inclusion, with a variety of different outcomes. We identified improvements in 24-h mortality for trauma (RR 0.88, 95% CI 0.84-0.92) and gastrointestinal bleeds (RR 0.30, 95% CI 0.23-0.39), and decreased long-term gastrointestinal bleed mortality (RR 0.57, 95% CI 0.48-0.69). We also identified an increase in TE risk in gastrointestinal bleeding scenarios (RR 1.45, 95% CI 1.09-1.94), but no other clinical scenarios. TXA is effective in reducing mortality following trauma and gastrointestinal bleeds, however, there is limited evidence at this time to support TXA administration in the context of subarachnoid haemorrhage. TE risk is elevated when used in gastrointestinal bleeds. Selective use in high-risk patients may be warranted. TXA should strongly be considered in management in ED and prehospital settings.