What is the correct timing for administering tranexamic acid (TXA) to a trauma patient, such as a 36-year-old male with a penetrating abdominal injury and multiple musculoskeletal fractures, based on the Pre-hospital Antifibrinolytics for Traumatic Coagulopathy and Hemorrhage (PATCH-Trauma) trial?

From the Guidelines

Tranexamic acid (TXA) should be administered within 3 hours after the time of injury before transport to the trauma center. In AJ's case, since only 90 minutes have elapsed since the collision, he is still within the optimal window for TXA administration. The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition 1 recommends that TXA be administered to the trauma patient who is bleeding or at risk of significant bleeding as soon as possible, if feasible en route to the hospital, and within 3 h after injury at a loading dose of 1 g infused over 10 min, followed by an i.v. infusion of 1 g over 8 h. Some key points to consider in the administration of TXA include:

• The standard dosing is 1 gram of TXA given intravenously as soon as possible after injury, followed by another 1 gram infused over 8 hours.
• Pre-hospital administration is beneficial because it allows the medication to begin working during the critical early period after trauma when coagulopathy develops.
• There is no requirement to perform liver function tests before administering TXA in the emergency trauma setting, nor is a CT scan of the head required prior to administration.
• Waiting until admission to the trauma center would delay treatment and potentially reduce TXA's effectiveness, as its benefit decreases with time from injury, as shown in the CRASH-2 trial 1. The use of TXA has been shown to reduce mortality in trauma patients with significant bleeding by inhibiting fibrinolysis and stabilizing blood clots, with the European guideline on management of major bleeding and coagulopathy following trauma: sixth edition 1 providing the most recent and highest quality evidence to support this recommendation.

From the Research

Administration of Tranexamic Acid (TXA)

• TXA should be administered within 3 hours after the time of injury before transport to the trauma center, as its effectiveness in reducing bleeding and mortality is most significant when used early after traumatic injury 2.
• There is no mention in the provided studies of the necessity to perform liver function tests prior to initiation of and during TXA therapy.
• A computed tomography (CT) scan of the head is not explicitly required prior to initiation of TXA to rule out hemorrhagic stroke in the context of the provided studies.
• The administration of TXA as a 1-g intravenous (IV) infusion over 1 hour starting at the time of admission to the trauma center is not specified in the provided studies as the standard protocol.

Considerations for TXA Use

• The use of TXA is supported by level 1 evidence for reducing bleeding in isolated orthopedic operations, but its safety and effectiveness in polytrauma patients outside the 3-hour window after injury are less clear 2.
• TXA has been used in various clinical scenarios involving bleeding, including trauma, postpartum, and orthopedic surgery, but substantial knowledge gaps remain regarding its dosing, pharmacokinetics, mechanism of action, and clinical applications 3.
• The risk of potential thromboembolic complications with the use of TXA must be balanced against its clinical benefits, and a more selective and individualized use of TXA is advocated 3.