What is the recommended treatment for excessive bleeding using Tranexamic Acid (TXA)?

Tranexamic Acid (TXA) for Excessive Bleeding

For excessive bleeding, tranexamic acid should be administered as early as possible at a loading dose of 1 g infused over 10 minutes, followed by an intravenous infusion of 1 g over 8 hours, and must be given within 3 hours of injury or bleeding onset for maximum benefit. 1

Dosing Protocol for Different Bleeding Scenarios

Trauma-Related Bleeding

• Timing: Administer as soon as possible, ideally within 1 hour of injury
• Dose: 1 g IV over 10 minutes, followed by 1 g IV over 8 hours
• Critical time window: Must be given within 3 hours of injury
• Pre-hospital administration: Consider administration en route to hospital 1
• Warning: Administration after 3 hours may increase risk of death due to bleeding 1

Postpartum Hemorrhage

• Dose: 1 g IV over 10 minutes
• Second dose: Additional 1 g if bleeding continues after 30 minutes or restarts within 24 hours
• Indication: For all cases of postpartum hemorrhage regardless of cause (uterine atony or genital tract trauma) 1
• Definition: Blood loss >500 mL after vaginal birth or >1000 mL after cesarean section, or any blood loss compromising hemodynamic stability

Other Bleeding Scenarios

• Surgical bleeding: Same dosing as trauma (1 g loading + 1 g infusion)
• Bleeding disorders: 10 mg/kg IV before procedures, then 10 mg/kg 3-4 times daily for 2-8 days 2

Mechanism and Evidence

TXA is a synthetic lysine analogue that competitively inhibits plasminogen activation, preventing fibrin breakdown and stabilizing clots. The CRASH-2 trial demonstrated that TXA significantly reduces:

• All-cause mortality (14.5% vs. 16.0%)
• Death due to bleeding (4.9% vs. 5.7%) 1

Early administration provides the greatest benefit:

• Within 1 hour: 32% reduction in death due to bleeding
• 1-3 hours: 21% reduction in death due to bleeding
• After 3 hours: Possible increased risk of death 1

Important Clinical Considerations

Do Not Delay Administration

• TXA should be given immediately upon recognition of significant bleeding
• Do not wait for laboratory confirmation of hyperfibrinolysis or coagulopathy 1
• Administration should not await results from viscoelastic assessment 1

Contraindications

• Subarachnoid hemorrhage (risk of cerebral edema and infarction)
• Active intravascular clotting
• Severe hypersensitivity to TXA 2
• Administration beyond 3 hours after injury 1

Potential Adverse Effects

• Seizures (with high doses)
• Hypotension (with rapid infusion)
• Visual disturbances
• Dizziness 2

Common Pitfalls to Avoid

1. Delayed administration: Efficacy decreases by 10% for every 15-minute delay
2. Restricting use to only severe cases: TXA should be given to all bleeding trauma patients, not just those with confirmed hyperfibrinolysis
3. Incorrect infusion rate: Infuse no more than 1 mL/minute to avoid hypotension
4. Dose adjustment: Reduce dosage in patients with renal impairment

Alternative Dosing Strategies

Recent evidence suggests that a single 2 g bolus may be as effective as the traditional 1 g bolus plus 1 g infusion regimen, with similar mortality rates and potentially fewer complications 3. However, current guidelines still recommend the standard protocol until more definitive evidence is available.

TXA should be considered part of the standard treatment package for bleeding, alongside other measures such as fluid replacement, hemostatic interventions, and surgical management as appropriate.