Tranexamic Acid in Trauma
Objective: Place TXA after bleeding control, only with clinical shock, only inside a 3-hour window — and never as a substitute for a tourniquet or an operating room.
Why This Matters
CRASH-2 showed a mortality benefit when TXA was given within 3 hours of injury for bleeding trauma patients. PATCH (prehospital, mature trauma systems) did not show better 6-month functional survival. STAAMP was mixed. The 2025 NAEMSP / ACEP / ACS-COT joint statement splits the difference: prehospital TXA may reduce mortality in adult hemorrhagic shock when given after life-saving interventions, appears safe, and should be given only with clinical signs of shock and no later than 3 hours post-injury.
If your service does not carry it, you are not failing the call. Tourniquets still outrank a drug.
- Bleed controlled — or packing/TQ/binder already working?
- Clinical hemorrhagic shock — not a dribble from a scalp
- Clock: injury time, not dispatch time. Past 3 hours → do not start TXA
- Label the dose so the hospital does not double-dose blindly
Where It Fits (Education)
- Adult trauma with signs of hemorrhagic shock (hypotension, marked tachycardia, obvious massive bleed) after MARCH interventions. See massive hemorrhage and damage-control resuscitation.
- NAEMSP 2025: either a 1 g IV/IO then hospital infusion, or a 2 g IV/IO slow push/infusion — ideal dose is not settled. This site does not choose. Protocol owns mixing and rate.
- Give it as an infusion or slow push as your card says. It is not adenosine.
Where It Does Not
- More than 3 hours from injury — CRASH-2 secondary analysis showed harm or no benefit late. Do not “catch up” at hour 5.
- No clinical bleeding/shock. Isolated minor trauma. Isolated TBI without hemorrhagic shock is a different evidence base (CRASH-3 was largely in-hospital).
- As a substitute for a tourniquet, packing, pelvic binder, or a surgeon.
Field Pitfalls
- Drawing TXA while arterial blood hits the ceiling.
- Forgetting to tell the trauma bay it was given (they may give another gram).
- Using dispatch time as injury time when the wreck was hours earlier.
Practice
60-second drill
Partner: (1) GSW, BP 78, TQ on, injury 20 minutes ago; (2) same patient, wreck 5 hours ago; (3) isolated ankle sprain. TXA yes/no and the one sentence you would radio to the trauma bay.
Related: Massive Hemorrhage First, Wound Packing, Med Rights.
Sources & Further Study
Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.
- NASEMSO National Model EMS Clinical Guidelines (2022) — U.S. EMS model language; protocol still wins
- NAEMSP / ACEP / ACS-COT 2025: Tranexamic Acid in Trauma — after LSIs, clinical shock, ≤3 hours; dose not settled
- CRASH-2 (in-hospital, 3-hour window); PATCH (prehospital, no 6-month functional benefit). Protocol owns whether you carry TXA.
Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.
Check Your Understanding
Street decisions from this lesson only. After you check, the key is highlighted. Education practice — not a certification exam.