🩺 THIS WEEK IN EM
Prehospital TXA in High-Risk Trauma: PATCH-Trauma Says the Story Is More Complicated Than You Think.
The PATCH-Trauma trial enrolled 1,310 adults with major trauma at high risk for trauma-induced coagulopathy — specifically patients selected by a COAST score suggesting significant coagulopathy risk, not simply a TBI diagnosis. That distinction matters. This was not a TBI-only trial. Patients were randomized to prehospital tranexamic acid (1 g IV bolus plus 1 g infusion over 8 hours) versus placebo. The primary outcome was favorable neurologic outcome at 6 months.
The result: no significant benefit. Favorable outcome occurred in 65% of the TXA group versus 62% of the placebo group. In other words, giving TXA early to a broadly defined high-risk trauma population did not improve the primary endpoint.
This does not cancel CRASH-2. It answers a different question. CRASH-2 asked whether TXA helps actively bleeding trauma patients. PATCH-Trauma asked whether empiric prehospital TXA in a trauma population at risk for coagulopathy improves functional outcome. That is not the same thing. If your patient has obvious major hemorrhage, CRASH-2 still matters. If your patient just looks “high risk” and you are using TXA as a prophylactic reflex, PATCH-Trauma should cool that enthusiasm.
Bottom line: PATCH-Trauma does not support routine empiric prehospital TXA for all high-risk major trauma patients. Use TXA where there is real concern for active major hemorrhage, not just theoretical coagulopathy.
PATCH-Trauma Investigators and the ANZICS Clinical Trials Group. Prehospital Tranexamic Acid for Severe Trauma. N Engl J Med. 2023;389(2):127-136.
1:1:1 Is Still the Ratio. PROPPR Settled That Part.
The PROPPR trial randomized 680 severely injured adults at 12 Level I trauma centers to receive either a 1:1:1 ratio of plasma:platelets:red blood cells or a 1:1:2 ratio during massive transfusion.
Overall 24-hour and 30-day mortality differences did not reach statistical significance. But the clinically important result did: the 1:1:1 group achieved hemostasis more often and had fewer deaths from exsanguination. That is not a trivial secondary signal. In trauma, bleeding to death early is the thing you are trying to prevent.
This is why 1:1:1 remains the reference framework for damage control resuscitation. If your system still behaves like plasma and platelets are optional DLC that arrive after red cells have already been flowing for half an hour, you are behind.
Bottom line: In massive transfusion, a balanced 1:1:1 plasma:platelet:RBC strategy remains the best-supported default and reduces death from exsanguination.
Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of Plasma, Platelets, and Red Blood Cells in a 1:1:1 vs a 1:1:2 Ratio and Mortality in Patients with Severe Trauma. JAMA. 2015;313(5):471-482.
Whole Blood in Trauma: Promising, But Let’s Not Pretend the Trial Data Is Cleaner Than It Is.
Whole blood is having a deserved comeback. The logic is obvious: one product, simpler logistics, early replacement of oxygen-carrying capacity, clotting factors, and platelets without the assembly-kit feel of component therapy. Prehospital programs and high-volume trauma centers are increasingly moving in this direction.
The problem is not biology. The problem is evidence quality. Much of the supportive data comes from military experience, retrospective civilian cohorts, and center-specific implementation studies. That is useful, but it is not the same as having a clean, definitive randomized trial proving a broad survival advantage over balanced component therapy.
So yes, whole blood is promising. Yes, systems that can support it should take it seriously. But no, we should not oversell certainty that the literature has not yet earned.
Bottom line: Whole blood is a strong evolving option in trauma resuscitation, especially in high-volume and prehospital systems, but the highest-quality comparative evidence is still maturing.
Joseph B, Azim A, Hassan A, et al.Whole blood resuscitation for injured patients requiring transfusion: A systematic review, meta-analysis, and practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2024.
📚 STILL CHANGING PRACTICE
If you haven’t internalized this yet, now’s the time.
CRASH-2 Is Still the TXA Trial That Actually Changed Practice.
CRASH-2 randomized more than 20,000 adult trauma patients with significant hemorrhage or risk of significant hemorrhage to TXA or placebo. It showed lower all-cause mortality and lower death from bleeding, especially when TXA was given early.
The timing point is the part people still manage to screw up. TXA is not a late-game cleanup drug. It works best when given early, ideally within 1 hour and still within 3 hours of injury. After 3 hours, the signal moves in the wrong direction.
So if you are going to use TXA, use it like a time-sensitive hemorrhage intervention — not as something you remember after the patient has already had a CT scan, three consults, and half their blood volume replaced.
Bottom line: Give TXA early in significant trauma hemorrhage. The earlier the better, and after 3 hours it may cause harm.
CRASH-2 Collaborators, Shakur H, Roberts I, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage. Lancet. 2010;376(9734):23-32.
Next Week 🔭
• Large core thrombectomy in stroke: SELECT-2 and ANGEL-ASPECT changed who gets the procedure
• Blood pressure management in intracerebral hemorrhage: The INTERACT3 data and what it means at the bedside
• Minimally invasive ICH evacuation: ENRICH trial results and the emerging role of the neurosurgeon
The Hallway Consult is built for EM clinicians who want the useful version of the literature. Forward it to a colleague if it helped.