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    Tranexamic Acid (TXA) in the Emergency Department


    Last Reviewed on Feb 03, 2024
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    • TXA is an antifibrinolytic agent used across multiple clinical settings for its ability to provide hemostatic control and improve clinical outcomes in patients that are bleeding.
    • Evidence suggests a modest mortality benefit when used for trauma resuscitation, but it’s utility and efficacy in other clinical scenarios is less clear and requires clinical judgement.
    • It does not seem to offer mortality benefit to patients with spontaneous intracranial, or subarachnoid, or gastrointestinal bleeding.
    • Optimal dosing in emergency settings is unclear.
      • Traditional dosing (based on the landmark CRASH 2 trial) is 1g IV over 10min, followed by 1g IV over the next 8 hrs.
      • Emerging evidence suggests that an alternative dose: 2g IV bolus upfront (instead of the traditional 1g + 1g) might be more convenient for providers without significant differences in mortality, functional outcomes, or adverse events.


    • TXA is a synthetic lysine analog that binds to plasminogen which prevents its conversion into plasmin. This results in inhibited fibrinolysis and reduced clot degradation.
    • Available PO, IV, IM, topically, or via nebulizer.
      • IM and IV administration share similar bioavailability and achieve therapeutic levels < 15 min.

    ED Applications

    • Trauma
    • Traumatic Brain Injury (TBI)
    • Intracranial Hemorrhage (ICH)
    • Subarachnoid Hemorrhage (SAH)
    • Gastrointestinal Bleeding (GIB)
    • Post-partum Hemorrhage (PPH)
    • Abnormal Uterine Bleeding
    • Epistaxis
    • Hemoptysis
    • Thrombolytic-induced Major Bleeding

    Recommended Treatment

    Related Information

    Reference List

    1. Wang K, Santiago R. Tranexamic acid – A narrative review for the emergency medicine clinician [published correction appears in Am J Emerg Med. 2022 May 23;:]. Am J Emerg Med. 2022;56:33-44. doi:10.1016/j.ajem.2022.03.027

    2. CRASH-2 trial collaborators, Shakur H, Roberts I, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 2010;376(9734):23-32. doi:10.1016/S0140-6736(10)60835-5

    3. Guyette FX, Brown JB, Zenati MS, et al. Tranexamic Acid During Prehospital Transport in Patients at Risk for Hemorrhage After Injury: A Double-blind, Placebo-Controlled, Randomized Clinical Trial [published correction appears in JAMA Surg. 2021 Jan 1;156(1):105]. JAMA Surg. Published online October 5, 2020. doi:10.1001/jamasurg.2020.4350

    4. Mitra B, Bernard S, Gantner D, et al. Protocol for a multicentre prehospital randomised controlled trial investigating tranexamic acid in severe trauma: the PATCH-Trauma trial. BMJ Open. 2021;11(3):e046522. Published 2021 Mar 15. doi:10.1136/bmjopen-2020-046522

    5. CRASH-3 trial collaborators. Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH-3): a randomised, placebo-controlled trial [published correction appears in Lancet. 2019 Nov 9;394(10210):1712]. Lancet. 2019;394(10210):1713-1723. doi:10.1016/S0140-6736(19)32233-0

    6. Rowell SE, Meier EN, McKnight B, et al. Effect of Out-of-Hospital Tranexamic Acid vs Placebo on 6-Month Functional Neurologic Outcomes in Patients With Moderate or Severe Traumatic Brain Injury [published correction appears in JAMA. 2020 Oct 27;324(16):1683]. JAMA. 2020;324(10):961-974. doi:10.1001/jama.2020.8958

    7. Sprigg, K. Flaherty, J.P. Appleton, R.A.,S. Salman, D. Bereczki, M. Beridze, et al.Tranexamic acid for hyperacute primary IntraCerebral Haemorrhage (TICH-2): an international randomised, placebo-controlled, phase 3 superiority trial Lancet. 2018;391(10135):2107-2115. doi:10.1016/S0140-6736(18)31033-X

    8. Post R, Germans MR, Tjerkstra MA, et al. Ultra-early tranexamic acid after subarachnoid haemorrhage (ULTRA): a randomised controlled trial. Lancet. 2021;397(10269):112-118. doi:10.1016/S0140-6736(20)32518-6

    9. HALT-IT Trial Collaborators. Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial. Lancet. 2020;395(10241):1927-1936. doi:10.1016/S0140-6736(20)30848-5

    10. Reuben A, Appelboam A, Stevens KN, et al. The Use of Tranexamic Acid to Reduce the Need for Nasal Packing in Epistaxis (NoPAC): Randomized Controlled Trial. Ann Emerg Med. 2021;77(6):631-640. doi:10.1016/j.annemergmed.2020.12.013

    11. WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial [published correction appears in Lancet. 2017 May 27;389(10084):2104]. Lancet. 2017;389(10084):2105-2116. doi:10.1016/S0140-6736(17)30638-4

    12. Singh S, Best C, Dunn S, Leyland N, Wolfman WL. No. 292-Abnormal Uterine Bleeding in Pre-Menopausal Women. J Obstet Gynaecol Can. 2018;40(5):e391-e415. doi:10.1016/j.jogc.2018.03.007


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