Tranexamic Acid and Seizures in Pediatric Trauma

Prehospital Tranexamic Acid Administration in Pediatric Trauma Patients: A Propensity-Matched Analysis of the Israeli Defense Forces Registry

OBJECTIVES

Tranexamic acid (TXA) administration confers a survival benefit in bleeding trauma patients; however, data regarding its use in pediatric patients are limited. This study evaluates the prehospital treatment with TXA in pediatric trauma patients treated by the Israel Defense Forces Medical Corps (IDF-MC).

DESIGN

Retrospective, cohort study using the Israel Defense Forces registry, 2011-2021.

PATIENTS

Pediatric trauma patients less than 18 years old. We excluded patients pronounced dead at the scene.

INTERVENTIONS

None.

SETTING

All cases of pediatric trauma in the registry were assessed for treatment with TXA. Propensity score matching was used to assess the association between prehospital TXA administration and mortality.

MEASUREMENTS AND MAIN RESULTS

Overall, 911 pediatric trauma patients were treated with TXA by the IDF-MC teams; the median (interquartile) age was 10 years (5-15 yr), and 72.8% were male. Seventy patients (7.6%) received TXA, with 52 of 70 (74%) receiving a 1,000 mg dose (range 200-1,000 mg). There were no prehospital adverse events associated with the use of TXA (upper limit of 95% CI for 0/70 is 4.3%). Compared with pediatric patients who did not receive TXA, patients receiving TXA were more likely to suffer from shock (40% vs 10.7%; p < 0.001), sustain more penetrating injuries (72.9% vs 31.7%; p < 0.001), be treated with plasma or crystalloids (62.9% vs 11.4%; p < 0.001), and undergo more lifesaving interventions (24.3% vs 6.2%; p < 0.001). The propensity score matching failed to identify an association between TXA and lesser odds of mortality, although a lack of effect (or even adverse effect) could not be excluded (non-TXA: 7.1% vs TXA: 4.3%, odds ratio = 0.584; 95% CI 0.084-3.143; p = 0.718).

CONCLUSIONS

Although prehospital TXA administration in the pediatric population is feasible with adverse event rate under 5%, more research is needed to determine the appropriate approach to pediatric hemostatic resuscitation and the role of TXA in this population.

Tranexamic acid-associated fatal status epilepticus in a pediatric non-cardiac surgery: A case report and literature review

Tranexamic acid (TXA) is widely utilized to control perioperative bleeding. TXA is considered a safe drug with few serious adverse effects, but many studies report TXA-associated seizures especially with cardiac surgeries. Usually, TXA-associated seizures persist for few minutes with no progression into status epilepticus. Here, we report, for the first time, a case of refractory status epilepticus after IV injection of TXA in a pediatric non-cardiac surgery. This case report and literature review aim to increase awareness about TXA-associated seizures and to provide mechanistic-based prevention and treatment recommendations. During adenotonsillectomy for a 4-year-old male child, TXA infusion started after induction of anesthesia for surgical bleeding prophylaxis. During recovery from anesthesia, the patient developed tonic-clonic convulsions which did not improve after two IV doses of midazolam but showed an improvement after a dose of propofol. The patients did not regain consciousness and was transferred to the ICU. He had recurrent treatment-resistant attacks of tonic-clonic convulsions. The patient developed acute kidney injury and died after 18 hours. In high-risk patients, using the lowest effective dose with early termination of TXA infusion and prolongation of administration of anesthetics may prevent seizures. General anesthetics (propofol and halogenated inhaled anesthetics) are considered the first line for prevention/treatment of TXA-associated seizures.