Tranexamic Acid (TXA)
Tranexamic acid
Brand names:Cyklokapron, Lysteda
A synthetic antifibrinolytic agent that stabilizes formed clots by blocking fibrin breakdown. The TCCC 2026 guidelines specify a single 2 gram IV/IO push for casualties with hemorrhagic shock or anticipated need for blood transfusion. The earlier CRASH-2 regimen (1 gram plus 1 gram) is now superseded for TCCC use but remains current in many civilian EMS protocols including PA Protocol 6094.
Pharmacology and Actions
Tranexamic acid is a lysine analogue that competitively inhibits the binding of plasminogen to fibrin. This prevents conversion of plasminogen to plasmin and stabilizes existing fibrin clots against fibrinolysis. The drug does not create new clots; it preserves the clots the body has already formed in response to bleeding. The clinical effect is reduced blood loss and reduced mortality from hemorrhage when administered within the therapeutic window (within 3 hours of injury).
Indications
- Hemorrhagic shock or anticipated need for blood transfusion (TCCC 2026)
- Significant traumatic hemorrhage within 3 hours of injury
- Penetrating torso trauma with signs of internal bleeding
- Major external hemorrhage not fully controlled by direct pressure and tourniquet
- Severe pelvic or femur fracture with suspected internal bleeding
- Postpartum hemorrhage (PA Protocol 7087 in select agencies)
Absolute Contraindications
- Known tranexamic acid allergy
- Active intravascular clotting or DIC with thrombotic predominance
- Time since injury greater than 3 hours (efficacy reduced; possible harm)
- Isolated head injury without other hemorrhage source (efficacy unclear)
- History of subarachnoid hemorrhage (relative; varies by protocol)
Precautions and Side Effects
TXA is generally well tolerated. Hypotension can occur with rapid IV push; administer slowly over 10 minutes when possible. Seizures have been associated with high-dose TXA, particularly in patients with renal impairment. Visual disturbances (color vision changes) have been reported with chronic use; not typically a concern with single trauma dosing. Nausea, vomiting, and diarrhea can occur. The drug should be administered as early as possible after injury; efficacy declines significantly after 1 hour and may cause harm after 3 hours.
Adult Dosing
Pediatric Dosing
Pediatric dosing is not addressed in primary TCCC doctrine. Civilian pediatric trauma dosing varies by protocol; typical regimen is 15 mg/kg IV/IO loading dose (maximum 1 gram), followed by 2 mg/kg/hr infusion. Consult medical control and local standing orders before administration.
Pharmacokinetics
Peak Effect: IV: 1 hour. Sustained antifibrinolytic effect for 3 to 8 hours after single dose.
Duration: Effect persists 3 to 8 hours after single 2 gram dose; longer with CRASH-2 protocol due to maintenance infusion.
Storage and Handling
Store ampules at controlled room temperature (15 to 30 degrees Celsius). Protect from light. TXA is stable in most field environments. Inspect for particulates before administration; discard if solution is cloudy or contains visible particles.
Reconstitution:
TXA is supplied as a sterile solution at 100 mg/mL (10 mL ampule contains 1 gram). For TCCC 2026 protocol, draw up 2 grams (20 mL) and administer slow IV/IO push. For CRASH-2 protocol, dilute 1 gram in 100 mL NSS for slow infusion.
TCCC and TECC Role
TXA is one of the most significant additions to TCCC over the past decade, with the 2026 update simplifying the regimen to a single 2 gram slow IV/IO push. The change from the CRASH-2 two-dose regimen reflects updated evidence showing equivalent efficacy with operationally simpler dosing. Administer TXA as early as possible after injury, ideally within the first hour. The drug pairs naturally with calcium administration during blood product resuscitation and is considered part of the modern damage-control resuscitation bundle in tactical and prolonged casualty care.
TXA is the drug that earned its place in every trauma kit through CRASH-2 and MATTERs trial evidence. The single-dose 2 gram protocol in TCCC 2026 is the right operational call: simpler to administer, no maintenance infusion to manage, and equivalent outcomes. The time window is what matters most. Every minute beyond the injury matters; efficacy at 3 hours is essentially zero and may cause harm. If you have any doubt whether the patient is bleeding significantly, the answer is administer TXA early.
Pushing TXA fast IV and causing hypotension. TXA should be diluted in 100 mL NSS and infused over 10 minutes when possible, or slow IV push over 1 to 2 minutes in austere environments. The drug's antifibrinolytic effect does not depend on rapid administration, but the hypotension from rapid push compounds existing shock. The other common error is administering TXA after the 3-hour window has closed, where evidence suggests harm may outweigh benefit.
This drug profile is provided as educational reference material for trained medical providers. It is not medical advice, not a substitute for formal training, and not a substitute for current published guidelines or medical direction.
Drug administration is governed by your scope of practice, agency standing orders, medical director protocols, and applicable state and federal regulations. Controlled substances are subject to additional handling, accountability, and documentation requirements per DEA and state law. Always verify dosing, indications, contraindications, and route of administration against current published guidelines and your local protocols before administration.
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Penn Tactical Solutions publishes this reference for educational purposes. PTS does not provide medical direction and does not assume responsibility for clinical decisions made in the field. Clinical responsibility rests with the administering provider, their medical director, and their agency.
Educational reference for trained medical providers. Not medical advice. Not a substitute for formal training, current published guidelines, or medical direction. Drug administration is governed by your scope of practice, agency standing orders, medical director protocols, and applicable state and federal regulations. Controlled substances require additional storage, accountability, and documentation per DEA and state law.
In a medical emergency, call 911. This reference is not a substitute for emergency medical services.
Verify dosing, indications, and contraindications against current published guidelines and your local protocols before administration. Confirm content currency against the source citation. Penn Tactical Solutions does not provide medical direction. Clinical responsibility rests with the administering provider, their medical director, and their agency.
Tranexamic Acid (TXA)
| IV/IO | TCCC 2026: 2 grams IV/IO slow push (single dose, no maintenance infusion required). PA Protocol 6094 (when adopted): 1 gram IV/IO over 10 minutes, followed by 1 gram over 8 hours (CRASH-2 regimen). Follow your specific agency protocol; PA agencies are transitioning from CRASH-2 to single-dose protocols at variable rates. (Antifibrinolytic effect: within minutes of administration) |
| IM | TCCC 2026 alternative when IV/IO not available: 1 gram IM, divided between two injection sites. (15 to 30 minutes) |
| PO | Oral TXA (650 mg tablets) is used for menorrhagia in non-emergency settings; not a prehospital indication. (1 to 3 hours) |