What is the recommended dose and administration of tranexamic acid (TXA) for infiltration into bleeding tissue?

Tranexamic Acid Infiltration into Bleeding Tissue

Direct tissue infiltration of tranexamic acid is not supported by current clinical guidelines, which exclusively recommend intravenous administration at 1 g over 10 minutes followed by 1 g over 8 hours for bleeding trauma patients. 1, 2

Standard Administration Route and Dosing

The evidence base for TXA is built entirely on intravenous delivery:

• Intravenous administration remains the only guideline-recommended route with proven mortality benefit in bleeding patients 1, 2, 3
• The WHO and European guidelines explicitly state their recommendations apply to IV administration only, as benefits and harms of other routes (including local infiltration) are considered a research priority 2
• Standard dosing is 1 g IV loading dose over 10 minutes, followed by 1 g infusion over 8 hours 1, 3, 4

Why Infiltration Is Not Recommended

Current evidence does not support local tissue infiltration for several critical reasons:

• No clinical trials have evaluated outcomes for direct tissue infiltration in bleeding trauma or surgical wounds 2
• The CRASH-2 trial, which established TXA's mortality benefit, used only systemic IV administration 1, 5
• TXA's mechanism requires systemic distribution to inhibit plasminogen activation throughout the circulation; local infiltration would not achieve therapeutic plasma levels 1

Topical Application Evidence (Not Infiltration)

The only non-IV evidence exists for topical application in specific anatomical sites:

• Topical TXA has been studied for anterior epistaxis using 1000 mg applied to nasal packing, showing reduced rebleeding rates compared to saline 6
• This represents surface application to mucosa, not deep tissue infiltration into bleeding wounds 6
• These findings cannot be extrapolated to infiltration of traumatic or surgical bleeding sites 7

Critical Timing Considerations

If you are considering TXA for a bleeding patient, timing supersedes route considerations:

• Effectiveness decreases by 10% for every 15-minute delay in administration 2, 3
• Treatment within 1 hour of injury provides maximum mortality reduction (RR 0.68) 1
• Administration after 3 hours post-injury may actually increase mortality due to bleeding (RR 1.44) 1, 3
• Pre-hospital IV administration should be prioritized over delayed hospital-based alternative routes 1

Common Pitfalls to Avoid

• Do not delay systemic IV TXA while attempting local infiltration techniques - this wastes the critical early treatment window 1, 3
• Do not assume local hemostatic effects justify infiltration without systemic absorption data 2
• Do not use higher doses than recommended (>2 g total), as this increases seizure risk particularly in neurosurgical contexts 8, 3

Practical Algorithm

For any bleeding patient where TXA is being considered:

1. Verify you are within 3 hours of injury onset - if beyond this window, TXA may cause harm 1, 3
2. Establish IV access immediately and administer 1 g over 10 minutes 1, 4
3. Follow with 1 g infusion over 8 hours 1, 3
4. Do not substitute or supplement with tissue infiltration 2

The evidence is unequivocal: use IV TXA according to established protocols or do not use it at all. 1, 2, 4