What are the indications for tranexamic acid (TXA) in an adult patient with a head injury and evidence of hemorrhage in the emergency department?

Indications for Tranexamic Acid in the Emergency Department

Tranexamic acid should be administered in the emergency department for trauma patients with significant bleeding or at risk of hemorrhage, and for patients with mild-to-moderate traumatic brain injury with intracranial hemorrhage—both within 3 hours of injury, with the greatest benefit achieved when given within 1 hour. 1

Primary Indications

Major Trauma with Hemorrhage

• Administer TXA to all trauma patients with significant bleeding or at risk of major hemorrhage within 3 hours of injury 1
• Patients treated within 1 hour of injury with a shock index <0.9 have a 65% lower likelihood of 30-day mortality (HR 0.35,95% CI 0.19-0.65) 1
• TXA reduces bleeding deaths by approximately one-third when given early 2
• The benefit decreases by 10% for every 15-minute delay in administration 3, 4

Traumatic Brain Injury (Mild-to-Moderate)

• TXA reduces head injury-related death by 22% (RR 0.78,95% CI 0.64-0.95) in patients with mild-to-moderate TBI when administered within 3 hours 1, 4
• Greatest benefit occurs in patients with:
  • GCS >3 4
  • Both pupils reactive at baseline 1, 4
  • Treatment initiated within 1 hour of injury 1, 4
• Do NOT administer to patients with severe TBI (GCS 3 with bilateral unreactive pupils)—no benefit demonstrated 4, 5

Standard Dosing Protocol

• Loading dose: 1g IV over 10 minutes 3, 4
• Maintenance infusion: 1g IV over 8 hours 3, 4
• Must be initiated within 3 hours of injury onset 1, 3
• Infuse no faster than 1 mL/minute to avoid hypotension 6

Absolute Contraindications (FDA Label)

• Subarachnoid hemorrhage—risk of cerebral edema and cerebral infarction 6
• Active intravascular clotting 6
• Severe hypersensitivity to tranexamic acid 6

Non-Indications in the Emergency Department

Non-Traumatic Intracranial Hemorrhage

• TXA is NOT indicated for spontaneous intracerebral hemorrhage—it reduces hematoma expansion but shows no mortality benefit (RR 1.02,95% CI 0.88-1.19) or improvement in functional outcomes (RR 0.98,95% CI 0.93-1.04) 7
• The American Heart Association/American Stroke Association guidelines do not recommend routine use for spontaneous ICH 7

Aneurysmal Subarachnoid Hemorrhage

• Contraindicated per FDA labeling 6
• While TXA reduces rebleeding risk (RR 0.6,95% CI 0.44-0.8), it increases cerebral ischemia/stroke risk (RR 1.29,95% CI 1.01-1.67) 7

Critical Implementation Pitfalls to Avoid

• Do NOT delay administration waiting for diagnostic workup, imaging, or viscoelastic testing—give empirically if clinical suspicion exists 4
• Do NOT administer after 3 hours from injury—late administration (>3 hours) may paradoxically increase bleeding death risk (RR 1.44,95% CI 1.12-1.84) 3, 4
• Do NOT restrict use to patients with documented hyperfibrinolysis on TEG/ROTEM—this approach would result in thousands of avoidable deaths 1, 2
• Do NOT use in patients with subarachnoid hemorrhage—this is an absolute FDA contraindication 6
• Do NOT substitute topical TXA when systemic hemostatic support is needed 3

Safety Profile

• No increased risk of arterial or venous thrombotic events demonstrated in over 8,000 trauma patients receiving TXA 3
• Meta-analysis of 125,550 participants confirms no increased thromboembolic risk 3
• Monitor for seizures, particularly with inadvertent neuraxial administration 6

Clinical Algorithm for ED Use

1. Identify trauma patient with bleeding or TBI within 3 hours of injury
2. Exclude absolute contraindications (subarachnoid hemorrhage, active DIC, severe hypersensitivity) 6
3. For mild-to-moderate TBI: Check pupillary reactivity and GCS—if both pupils reactive and GCS >3, administer TXA 4, 5
4. For major trauma with hemorrhage: Administer TXA immediately without waiting for labs or imaging 1
5. Initiate within 1 hour if possible for maximum mortality benefit 1, 4
6. Do NOT give if >3 hours from injury 3, 4