Tranexamic acid for acute bleeding in severely traumatized patients: Mortality, neurological outcomes, and thromboembolic risk

BACKGROUND: The optimal use of tranexamic acid (TXA) in trauma care is a matter of intense discussion, particularly with respect to its indications, dosage, temporal window, and thromboembolic adverse effects. METHODS: This review is based on publications retrieved by a selective literature search on the indications, effects, mechanism of action, and side effects of TXA (January 2022 to December 2025). Three randomized, controlled trials (RCTs), three observational studies, eight secondary analyses, and 16 meta-analyses were evaluated. RESULTS: TXA administration lowers the mortality of severely traumatized patients (e.g., with a relative risk [RR] of 0.73 [0.56;0.96]). The currently available evidence is inconsistent, and many of the effects found in published studies lie within the range of random fluctuation. The reduction of mortality depends on TXA administration at the earliest possible time in the first 90 minutes after trauma (this temporal window is more important than the question of pre- vs. in-hospital administration), as well as on the nature of the injury, particularly in patients with hemorrhagic shock. Among patients with isolated traumatic brain injury, no consistent effect on mortality has been shown, but there may be an effect on the progression of intracranial bleeding. Multiple studies point to a thromboembolic risk, which is dose-dependent, with a marked rise at 4 g (hazard ratio [HR] 5.33, 95% confidence interval [1.94;14.63]). In patients without shock, the reported absolute risk difference for mortality ranges from -5% to +5%, and that for thromboembolic adverse events from -0.2% to +4%. CONCLUSION: For trauma patients with life-threatening hemorrhage, especially those in hemorrhagic shock, it is recommended that TXA be given as early as possible (before arrival in the hospital) in a single dose of 1-2 g (15-30 mg/kg body weight [BW]). When this is done, the benefit appears to be greater than the thromboembolic risk.