What is the recommended dose of Tranexamic Acid (TXA) in an emergency setting?

Recommended TXA Dose in Emergency Settings

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

Standard Dosing Protocol

The evidence strongly supports a two-phase dosing regimen for trauma patients with active bleeding or hemorrhagic shock:

• Loading dose: 1 g IV over 10 minutes 1, 2
• Maintenance infusion: 1 g IV over 8 hours 1, 2
• Infusion rate caution: Administer no faster than 1 mL/minute to avoid hypotension 3

Critical Timing Considerations

Time is absolutely critical for TXA effectiveness:

• Optimal window: Administer within 3 hours of injury 1, 2
• Effectiveness decay: TXA loses approximately 10% effectiveness for every 15-minute delay 2, 4
• After 3 hours: Administration beyond 3 hours may actually increase risk of death from bleeding and should be avoided 2, 4, 5
• Pre-hospital administration: Consider giving the first dose en route to hospital to ensure early treatment 1, 2

Alternative Dosing Strategy

Recent evidence suggests a simplified approach may be equally effective:

• Single 2 g bolus: A 2024 comparative study found that a single 2 g IV bolus produced equivalent 28-day mortality (21%) compared to the traditional 1 g + 1 g infusion regimen 6
• Practical advantage: Single bolus administration eliminates the need for prolonged infusion management 6
• Current joint position: The 2025 NAEMSP/ACEP/ACS-COT statement acknowledges either a 1 g dose (with hospital-based 1 g infusion) or a 2 g dose as acceptable options 5

Patient Selection Criteria

Administer TXA to trauma patients with:

• Active bleeding or at risk of significant hemorrhage 1
• Clinical signs of hemorrhagic shock (hypotension, tachycardia, altered mental status) 5
• Base deficit >6 mEq/L indicating hypoperfusion 1

Do NOT administer TXA in:

• Patients beyond 3 hours post-injury 2, 5
• Active intravascular clotting 3
• Subarachnoid hemorrhage (contraindicated due to risk of cerebral edema and infarction) 3
• Known hypersensitivity to tranexamic acid 3

Dose Adjustments for Renal Impairment

Reduce dosing in patients with renal dysfunction: 3

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

Pediatric Considerations

• No established prehospital dosing: The role of TXA in pediatric trauma has not been adequately studied 5
• If used: Administer within 3 hours of injury, though specific weight-based dosing remains undefined 5
• Alternative reference: Some guidelines suggest 15 mg/kg loading dose followed by 2 mg/kg/hour infusion for pediatric trauma, though this is extrapolated from adult data 2

Safety Monitoring

Key adverse events to monitor:

• Seizures: Most commonly reported with doses >100 mg/kg, particularly in cardiac surgery (not trauma) settings 2, 3
• Thromboembolism: Risk appears low in trauma patients; CRASH-2 trial showed lower thrombosis rates with TXA compared to placebo 1
• Hypotension: Can occur with rapid infusion; maintain infusion rate ≤1 mL/minute 3
• Hypersensitivity reactions: Including anaphylaxis; discontinue immediately if occurs 3

Route of Administration

• Intravenous is the only recommended route for emergency trauma use 2, 4
• Intraosseous access is acceptable if IV access cannot be obtained 5
• Never administer intrathecally: Serious adverse reactions including seizures and cardiac arrhythmias have occurred with inadvertent neuraxial administration 3

Common Pitfalls to Avoid

• Delaying administration: Every 15-minute delay reduces effectiveness by 10%; prioritize early administration 2
• Giving after 3 hours: This may harm rather than help the patient 2, 5
• Using in isolated traumatic brain injury without hemorrhagic shock: Evidence supports TXA in TBI only when administered within 3 hours for mild-moderate injury, but standard trauma dosing applies 2
• Confusing with other injectable solutions: Clearly label syringes with "IV ONLY" to prevent wrong-route errors 3
• Mixing with incompatible solutions: Do not mix with blood products or penicillin-containing solutions 3

Communication and Quality Assurance

• Document and communicate: Clearly inform receiving hospital staff of TXA administration to prevent duplicate dosing 5
• Quality monitoring: Establish multidisciplinary oversight including EMS physicians, emergency physicians, and trauma surgeons to track protocol compliance and complications 5