Tranexamic Acid in Trauma
Recommended Dosing and Administration
Administer tranexamic acid 1 g intravenously over 10 minutes as a loading dose, followed by 1 g infusion over 8 hours, starting as early as possible and within 3 hours of injury. 1, 2
Critical Timing Considerations
The treatment window is time-critical: effectiveness decreases by 10% for every 15-minute delay in administration. 1
Maximum benefit occurs when TXA is given within 1-2 hours of injury, with the greatest relative risk reduction in 24-hour mortality observed in this early window. 3, 4
Administration within 3 hours of injury reduces hemorrhage-related death by approximately one-third. 1, 5
Do not administer TXA after 3 hours post-injury, as late administration may paradoxically increase the risk of death due to bleeding rather than provide benefit. 1, 2, 3
Administration Route and Technique
Intravenous administration is the only evidence-based and guideline-recommended route. 1, 6
Infuse no faster than 1 mL/minute to avoid hypotension. 7
Pre-hospital administration should be strongly considered to ensure treatment begins within the optimal time window. 1, 2
Intramuscular administration lacks clinical trial evidence and is not included in current guidelines, though the 3-hour window would still apply if used. 6
Patient Selection
Administer to all trauma patients who are bleeding or at risk of significant hemorrhage, as recommended by the American College of Critical Care. 2
Do not restrict use to only the most severely injured patients or those with confirmed hyperfibrinolysis, as this approach would result in thousands of avoidable deaths. 5
For patients with traumatic brain injury (particularly mild to moderate severity), TXA reduces head injury-related death when given within 3 hours. 1, 2
In severe traumatic brain injury (GCS < 9), treatment benefits may extend beyond the 2-hour window, potentially up to 3 hours. 4
Dose Adjustments for Renal Impairment
For serum creatinine 1.36-2.83 mg/dL: reduce to 10 mg/kg twice daily 7
For serum creatinine 2.83-5.66 mg/dL: reduce to 10 mg/kg once daily 7
For serum creatinine >5.66 mg/dL: reduce to 10 mg/kg every 48 hours or 5 mg/kg every 24 hours 7
Safety Profile and Contraindications
TXA is contraindicated in patients with subarachnoid hemorrhage due to risk of cerebral edema and infarction. 7
Do not use in patients with active intravascular clotting. 7
Higher doses are associated with increased seizure risk, particularly in cardiac surgery patients, but the standard trauma dose (2 g total) has an acceptable safety profile. 1, 2
No significant increase in thrombotic events has been demonstrated in trauma patients receiving TXA at standard dosing. 2
Avoid concomitant use with pro-thrombotic agents including Factor IX concentrates, anti-inhibitor coagulant concentrates, and hormonal contraceptives. 7
Critical Pitfalls to Avoid
Never delay TXA administration waiting for laboratory results or viscoelastic testing—early administration is paramount. 2
Do not administer intrathecally—serious adverse reactions including seizures and cardiac arrhythmias have occurred with incorrect route of administration. 7
Do not mix TXA with blood products or penicillin-containing solutions. 7
The diluted mixture may be stored for up to 4 hours at room temperature; discard any unused portion thereafter. 7