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Prehospital Tranexamic Acid Use for Traumatic Brain Injury (TXA)

This study is ongoing, but not recruiting participants.
Sponsor:
Collaborators:
National Heart, Lung, and Blood Institute (NHLBI)
U.S. Army Medical Research and Materiel Command
Canadian Institutes of Health Research (CIHR)
Heart and Stroke Foundation of Canada
American Heart Association
Defence Research and Development Canada
Information provided by (Responsible Party):
Susanne May, University of Washington
ClinicalTrials.gov Identifier:
NCT01990768
First received: October 30, 2013
Last updated: March 5, 2017
Last verified: March 2017
  Purpose

Primary aim: To determine the efficacy of two dosing regimens of TXA initiated in the prehospital setting in patients with moderate to severe TBI (GCS score ≤12).

Primary hypothesis: The null hypothesis is that prehospital administration either of two dosing regimens of TXA in patients with moderate to severe TBI will not increase the proportion of patients with a favorable long-term neurologic outcome compared to placebo, based on the GOS-E at 6 months.

Secondary aims: To determine differences between TXA and placebo in the following outcomes for patients with moderate to severe TBI treated in the prehospital setting with 2 dosing regimens of TXA:

  • Clinical outcomes: ICH progression, DRS at discharge and 6 months, GOS-E at discharge, 28-day survival, frequency of neurosurgical interventions, and ventilator-free, ICU-free, and hospital-free days.
  • Safety outcomes: Development of seizures, cerebral ischemic events, myocardial infarction, deep venous thrombosis, and pulmonary thromboembolism.
  • Mechanistic outcomes: Alterations in fibrinolysis based on fibrinolytic pathway mediators and degree of clot lysis based on TEG.

Inclusion: Blunt and penetrating traumatic mechanism consistent with TBI with prehospital GCS ≤ 12 prior to administration of sedative and/or paralytic agents, prehospital SBP ≥ 90 mmHg, prehospital IV or intraosseous (IO) access, age ≥ 15yrs (or weight ≥ 50kg if age is unknown), EMS transport to a participating trauma center.

Exclusion: GCS=3 with no reactive pupil, estimated time from injury to hospital arrival >2 hours, unknown time of injury, clinical suspicion by EMS of seizure activity or known history of seizures, acute MI or stroke, CPR by EMS prior to randomization, burns > 20% TBSA, suspected or known prisoners, suspected or known pregnancy, prehospital TXA given prior to randomization, subjects who have activated the "opt-out" process when required by the local regulatory board.

A multi-center double-blind randomized controlled trial with 3 treatment arms:

  • Bolus/maintenance: 1 gram IV TXA bolus in the prehospital setting followed by a 1 gram IV maintenance infusion initiated on hospital arrival and infused over 8 hours.
  • Bolus only: 2 grams IV TXA bolus in the prehospital setting followed by a placebo maintenance infusion initiated on hospital arrival and infused over 8 hours.
  • Placebo: Placebo IV bolus in the prehospital setting followed by a placebo maintenance infusion initiated on hospital arrival and infused over 8 hours.

Condition Intervention Phase
Traumatic Brain Injury Drug: 1 gram Tranexamic Acid (TXA) Drug: 2 grams TXA Drug: 0.9% Sodium Chloride injectable Phase 2

Study Type: Interventional
Study Design: Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)
Primary Purpose: Treatment
Official Title: Prehospital Tranexamic Acid Use for Traumatic Brain Injury

Resource links provided by NLM:


Further study details as provided by Susanne May, University of Washington:

Primary Outcome Measures:
  • Glasgow Outcome Scale Extended score (GOS-E) [ Time Frame: 6 months post-injury ]
    GOS-E subdivides the categories of severe and moderate disability and good recovery. Structured telephone interviews have been developed and validated for both the GOS and GOS-E and these questions will be incorporated into our follow-up survey. For each level of function, the baseline function prior to injury is assessed to ensure that the deficit can be attributed to the event.


Secondary Outcome Measures:
  • Observed volume (absolute and relative) of intracranial hemorrhage (ICH) progression [ Time Frame: On hospital arrival through 28 days or from hospital admission through the end of the hospital stay, an expected average of 14 days post injury ]
    All clinically indicated head CT scans obtained during the initial hospitalization or within the first 28 days will be assessed for ICH. All cerebral and carotid/vertebrobasilar CT and standard angiograms will be assessed for blunt cerebrovascular injury. Parenchymal, subdural and epidural hemorrhage volumes will be measured and quantified using volumetric software and verified by manual calculations based on the previously validated ABC/2 technique as needed.

  • Disability Rating Scale (DRS) [ Time Frame: At the end of the hospital stay, an expected average of 14 days post injury, and 6 months post injury ]
    The DRS is designed to classify patients based on their degree of function after brain injury. The DRS consists of 8 items that fall into 4 categories: a) arousability, awareness and responsivity, b) cognitive ability for self-care activities, c) dependence on others, and 3) psychosocial adaptability.

  • GOS-E [ Time Frame: At the end of the hospital stay, an expected average of 14 days post injury ]
    GOS-E subdivides the categories of severe and moderate disability and good recovery. Structured telephone interviews have been developed and validated for both the GOS and GOS-E and these questions will be incorporated into our follow-up survey. For each level of function, the baseline function prior to injury is assessed to ensure that the deficit can be attributed to the event.

  • Survival [ Time Frame: 28 days after hospital arrival ]
    The patient's vital status as either alive or dead at 28 days after hospital arrival.

  • Frequency of neurosurgical interventions [ Time Frame: From hospital admission through the end of the hospital stay, an expected average of 14 days post injury ]
    Neurosurgical interventions are surgical procedures required to treat traumatic brain injury.

  • Ventilator-free days [ Time Frame: From hospital admission through day 28 ]
    Ventilator-free days count any day from hospital admission through day 28 that the patient does not require mechanical ventilatory support.

  • Seizure [ Time Frame: From hospital admission through the end of the hospital stay, an expected average of 14 days post injury ]
    Seizures may cause involuntary changes in body movement or function, sensation, awareness, or behavior. Seizures are often associated with a sudden and involuntary contraction of a group of muscles and loss of consciousness.

  • Cerebral ischemic events [ Time Frame: From hospital admission through the end of the hospital stay, an expected average of 14 days post injury ]
    New focal ischemic lesions will be defined as an area of focal low attenuation in a distribution indicating an arterial ischemic cause rather than a traumatic contusion and will be rated using a validated scale for ischemic stroke.

  • Myocardial infarction [ Time Frame: From hospital admission through the end of the hospital stay, an expected average of 14 days post injury. ]
    Diagnosis of an acute myocardial infarction

  • Deep vein thrombosis (DVT) [ Time Frame: From hospital admission through the end of the hospital stay, an expected average of 14 days post injury ]
    Diagnosis of an DVT

  • Pulmonary embolus (PE) [ Time Frame: From hospital admission through the end of the hospital stay, an expected average of 14 days post injury ]
    Diagnosis of PE


Other Outcome Measures:
  • Alterations in fibrinolysis [ Time Frame: From hospital admission through 48 hours ]
    Alterations in fibrinolysis based on fibrinolytic pathway mediators and degree of clot lysis based on kaolin activated TEG and defined as LY30 or the per cent lysis that occurs 30 minutes after maximum amplitude (MA) is achieved.


Enrollment: 967
Study Start Date: May 2015
Estimated Study Completion Date: December 31, 2017
Estimated Primary Completion Date: October 31, 2017 (Final data collection date for primary outcome measure)
Arms Assigned Interventions
Experimental: 1 gram Tranexamic Acid (TXA)
Loading dose of 1 gram TXA given prior to hospital arrival followed by a 1 gram TXA infusion over 8 hours after hospital arrival
Drug: 1 gram Tranexamic Acid (TXA)
TXA produces an antifibrinolytic effect by competitively inhibiting the activation of plasminogen to plasmin.
Other Name: Cyklokapron
Experimental: 2 grams TXA
Loading dose of 2 gram TXA given prior to hospital arrival followed by a placebo of 0.9% Sodium Chloride solution infusion over 8 hours after hospital arrival
Drug: 2 grams TXA
TXA produces an antifibrinolytic effect by competitively inhibiting the activation of plasminogen to plasmin.
Other Name: Cyklokapron
Placebo Comparator: 0.9% Sodium Chloride injectable
Loading dose of 0.9% Sodium Chloride solution given prior to hospital arrival followed by a placebo of 0.9% Sodium Chloride solution infusion over 8 hours after hospital arrival
Drug: 0.9% Sodium Chloride injectable
Loading dose of 0.9% Sodium Chloride solution given prior to hospital arrival followed by a placebo of 0.9% Sodium Chloride solution infusion over 8 hours after hospital arrival. No active drug is added to the solution.
Other Name: Normal saline solution

  Show Detailed Description

  Eligibility

Ages Eligible for Study:   15 Years and older   (Child, Adult, Senior)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

  1. Blunt or penetrating traumatic mechanism consistent with traumatic brain injury
  2. Prehospital Glasgow Coma Score (GCS) score ≤ 12 at any time prior to randomization and administration of sedative and/or paralytic agents
  3. Prehospital systolic blood pressure (SBP) ≥ 90 mmHg prior to randomization
  4. Prehospital intravenous (IV) or intraosseous (IO) access
  5. Estimated Age ≥ 15 (or estimated weight > 50 kg if age is unknown)
  6. Emergency Medicine System (EMS) transport to a participating trauma center

Exclusion Criteria:

  1. Prehospital GCS=3 with no reactive pupil
  2. Estimated time from injury to hospital arrival > 2 hours
  3. Unknown time of injury - no known reference times to support estimation
  4. Clinical suspicion by EMS of seizure activity or known history of seizures, acute myocardial infarction (MI) or stroke
  5. Cardio-pulmonary resuscitation (CPR) by EMS prior to randomization
  6. Burns > 20% total body surface area (TBSA)
  7. Suspected or known prisoners
  8. Suspected or known pregnancy
  9. Prehospital TXA given prior to randomization
  10. Subjects who have activated the "opt-out" process when required by the local regulatory board
  Contacts and Locations
Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the Contacts provided below. For general information, see Learn About Clinical Studies.

Please refer to this study by its ClinicalTrials.gov identifier: NCT01990768

Locations
United States, Alabama
Alabama Resuscitation Center
Birmingham, Alabama, United States, 35249
United States, Minnesota
Hennepin County Medical Center
Minneapolis, Minnesota, United States, 55415
Mayo Clinic Rochester
Rochester, Minnesota, United States, 55905
St Paul Regions Hospital
St Paul, Minnesota, United States, 55101
United States, Ohio
University of Cincinnati Medical Center
Cincinnati, Ohio, United States, 45267
United States, Oregon
Oregon Health & Sciences University
Portland, Oregon, United States, 97239-3098
United States, Texas
Dallas Center for Resuscitation Research
Dallas, Texas, United States, 75390
Memorial Hermann Hospital - Texas Medical Center
Houston, Texas, United States, 77030
United States, Washington
Harborview Medical Center
Seattle, Washington, United States, 98104
United States, Wisconsin
Milwaukee Resuscitation Research Center
Milwaukee, Wisconsin, United States, 53226
Canada, British Columbia
British Columbia Regional Coordinating Center
Vancouver, British Columbia, Canada, V5Z 1 M9
Canada, Ontario
Toronto RescuNet
Toronto, Ontario, Canada, M5B 1W8
Sponsors and Collaborators
University of Washington
National Heart, Lung, and Blood Institute (NHLBI)
U.S. Army Medical Research and Materiel Command
Canadian Institutes of Health Research (CIHR)
Heart and Stroke Foundation of Canada
American Heart Association
Defence Research and Development Canada
Investigators
Principal Investigator: Susanne May, PhD University of Washington
Principal Investigator: Martin Schreiber, MD FACS Oregon Health and Science University
  More Information

Responsible Party: Susanne May, Associate Professor, University of Washington
ClinicalTrials.gov Identifier: NCT01990768     History of Changes
Other Study ID Numbers: 47114-A
5U01HL077863-09 ( U.S. NIH Grant/Contract )
TATRC Log No. 13335004-A ( Other Grant/Funding Number: US Army Medical Research Acquisition Activity (USAMRAA) )
Study First Received: October 30, 2013
Last Updated: March 5, 2017
Individual Participant Data (IPD) Sharing Statement:
Plan to Share IPD: Yes
Plan Description: Public use data set will be shared with NHLBI. It will include individual patient data that are de-identified. It will be available 3 years after study completion. This is currently expected for the end of 2020. The data should then be available at <https://biolincc.nhlbi.nih.gov/studies/>.

Keywords provided by Susanne May, University of Washington:
tranexamic acid
traumatic brain injury
intracranial hemorrhage
prehospital
neurologic outcome
glasgow outcome scale extended
disability rating scale

Additional relevant MeSH terms:
Wounds and Injuries
Brain Injuries
Brain Diseases
Central Nervous System Diseases
Nervous System Diseases
Craniocerebral Trauma
Trauma, Nervous System
Pharmaceutical Solutions
Tranexamic Acid
Antifibrinolytic Agents
Fibrin Modulating Agents
Molecular Mechanisms of Pharmacological Action
Hemostatics
Coagulants

ClinicalTrials.gov processed this record on September 20, 2017