When to use Tranexamic Acid (TXA) to promote clotting in a patient?

When to Use Tranexamic Acid (TXA) for Hemostasis

Administer TXA 1g IV over 10 minutes followed by 1g infusion over 8 hours to any trauma patient who is bleeding or at risk of significant hemorrhage, ideally within 3 hours of injury onset. 1

Primary Clinical Indications

Trauma-Related Hemorrhage (Strongest Evidence)

• TXA reduces all-cause mortality by 9% and bleeding-related death by 15% in trauma patients based on the landmark CRASH-2 trial of over 20,000 patients. 2
• Early administration (≤1 hour from injury) reduces bleeding death by 32%, while treatment between 1-3 hours still provides 21% reduction. 2
• The benefit applies regardless of systolic blood pressure, Glasgow coma score, or type of injury. 1
• Pre-hospital administration should be considered to ensure treatment within the critical 3-hour window. 1, 2

Surgical Hemorrhage

• Administer TXA to patients undergoing major surgery with high risk of significant bleeding, including orthopedic procedures, cardiac surgery, and gynecologic operations. 2
• For procedures expected to exceed 2-3 hours, continue the maintenance infusion of 1g over 8 hours. 2
• Give the loading dose prior to incision for maximum efficacy. 2

Postpartum Hemorrhage

• Administer TXA within 3 hours of birth for all clinically diagnosed postpartum hemorrhage (>500 mL vaginal delivery, >1000 mL cesarean), regardless of whether bleeding is due to genital tract trauma or uterine atony. 2, 3
• If bleeding continues after 30 minutes or recurs within 24 hours, give a second 1g dose. 2

Traumatic Brain Injury

• TXA reduces head injury-related death when administered within 3 hours, particularly in mild to moderate traumatic brain injury. 2, 3

FDA-Approved Indication

• TXA is FDA-approved for patients with hemophilia undergoing tooth extraction at 10 mg/kg IV immediately before the procedure, followed by 10 mg/kg 3-4 times daily for 2-8 days. 4

Critical Timing Algorithm

The effectiveness of TXA is time-dependent and follows this pattern:

• ≤1 hour from injury: Maximum benefit (32% reduction in bleeding death) 2
• 1-3 hours: Moderate benefit (21% reduction in bleeding death) 2
• >3 hours: NO BENEFIT and potentially harmful (may increase bleeding death risk) 1, 2, 3
• Efficacy decreases by 10% for every 15-minute delay in administration. 2, 3

Standard Dosing Protocol

Loading dose: 1g IV over 10 minutes (infuse no faster than 1 mL/minute to avoid hypotension) 1, 2, 3, 4

Maintenance: 1g IV infusion over 8 hours 1, 2, 3

Dose Adjustments for Renal Impairment

TXA is renally excreted and requires dose reduction in renal failure: 2, 4

• Serum creatinine 1.36-2.83 mg/dL: 10 mg/kg twice daily 4
• Serum creatinine 2.83-5.66 mg/dL: 10 mg/kg once daily 4
• Serum creatinine >5.66 mg/dL: 10 mg/kg every 48 hours or 5 mg/kg every 24 hours 4

Absolute Contraindications

Do NOT administer TXA in these situations:

• Active intravascular clotting or disseminated intravascular coagulation 2, 4
• Subarachnoid hemorrhage (aneurysmal or traumatic)—routine use does not improve functional outcomes and may cause cerebral edema and infarction 5, 4
• Severe hypersensitivity to tranexamic acid 2, 4

Relative Contraindications and Cautions

Use with extreme caution in: 2

• Massive hematuria
• Patients on oral contraceptive pills (increased thrombotic risk)
• Post-stroke patients
• Patients requiring thrombolytic therapy (TXA counteracts thrombolytics) 3

Safety Profile

No increased risk of thrombotic events (myocardial infarction, stroke, DVT, pulmonary embolism) has been demonstrated in over 8,000 trauma and surgical patients receiving TXA. 1, 2

Important Safety Considerations:

• Higher doses (>100 mg/kg total) are associated with increased seizure risk, particularly in cardiac surgery. 2, 3
• One case-control study in women with menorrhagia suggested possible increased venous thrombosis risk, but this has not been confirmed in major bleeding scenarios. 6
• Gastrointestinal bleeding may carry increased venous thrombosis risk with TXA use. 7

Key Clinical Pitfalls to Avoid

1. Do not delay TXA administration waiting for laboratory confirmation of coagulopathy or hyperfibrinolysis—early empiric treatment is critical. 2, 8
2. Do not administer TXA after 3 hours from injury onset, as this may paradoxically increase mortality. 1, 2, 3
3. Do not use topical TXA as a substitute for IV administration when systemic hemostatic support is needed—systemic fibrinolysis requires systemic treatment. 2
4. Do not exceed 100 mg/kg total dose to minimize seizure risk. 3
5. Do not infuse faster than 1 mL/minute to avoid hypotension. 4
6. Do not use in patients with subarachnoid hemorrhage, even in the trauma setting. 5, 4

Clinical Decision Algorithm

For any patient with active bleeding or high bleeding risk:

1. Identify the clinical scenario (trauma, surgery, postpartum, etc.)
2. Check time from bleeding onset (must be <3 hours for benefit)
3. Screen for absolute contraindications (active clotting, SAH, hypersensitivity)
4. Assess renal function (adjust dose if impaired)
5. Administer 1g IV over 10 minutes immediately
6. Follow with 1g infusion over 8 hours (if procedure/bleeding continues >2-3 hours)
7. Do not delay for laboratory results or imaging