Tranexamic Acid (TXA)

Emergency & Prehospital

• Traumatic hemorrhage (EMS): Give it to adults with clinical signs of hemorrhagic shock, after lifesaving steps such as hemorrhage control. The window closes at 3 hr after injury, and earlier is better, ideally within 1 hr. There is no evidence of benefit in patients without clinically significant bleeding (off-label).
• Postpartum hemorrhage (PPH): Start it as soon as PPH is diagnosed, and within 3 hr of birth. It goes in alongside uterotonics as part of the first-response bundle. WHO 2025 diagnosis: objectively measured blood loss of 500 mL or more, or 300 mL or more with any abnormal vital sign (pulse >100/min, shock index >1, systolic BP <100 mmHg or diastolic BP <60 mmHg). Give it for PPH of any cause, whether atony or genital tract trauma, without waiting to find the source (off-label in the US).

ED / ICU / Transport

• Traumatic hemorrhage (hospital): Trauma patients who are bleeding, or at significant risk of bleeding. Start as soon as possible and within 3 hr of injury, per the European trauma guideline (off-label).
• Traumatic brain injury (TBI): The evidence is limited, so give only per local protocol. CRASH-3's primary outcome was not significant. A subgroup analysis found that hospital patients with mild-to-moderate TBI treated within 3 hr had fewer head-injury deaths. Prehospital TXA has shown no functional or survival benefit in moderate-to-severe TBI (off-label).
• Massive hemorrhage protocols: Finish the 8-hr infusion after a prehospital or ED bolus. It is an adjunct to blood products and hemorrhage control, never a substitute.
• Bleeding after fibrinolytic therapy: Use it as an adjunct under the stroke or fibrinolytic protocol. See fibrinolytics (off-label).

Other Uses

• Hemophilia, tooth extraction: This is short-term IV use (2–8 days) to reduce bleeding and the need for replacement therapy. It is the FDA-labeled IV indication.
• Cyclic heavy menstrual bleeding: Given as oral tablets. This is the FDA-labeled oral indication.
• Surgical blood loss: Used in orthopedic, cardiac and other surgery, under anesthesia protocols (off-label).
• Mucosal bleeding: Topical use for epistaxis, or nebulized use for non-massive hemoptysis, under institutional protocol. In a large UK ED trial, topical TXA did not reduce the need for nasal packing (off-label).

Not Recommended

• Gastrointestinal (GI) bleeding: It did not reduce deaths from bleeding. There was more venous thromboembolism (VTE).
• Routine PPH prevention: Skip it at vaginal or cesarean birth. The WHO 2025 guideline does not recommend it there.
• Starting more than 3 hr after injury or birth: There is no benefit. In trauma, late treatment increased death from bleeding.

Evidence by Indication

The doses below come from guidelines. The first trauma regimen is off-label. The FDA label differs: its only IV indication is hemophilia tooth extraction, at 10 mg/kg.

Available Forms

• Injection: 100 mg/mL, 1,000 mg in 10 mL single-dose vial or ampule (Cyklokapron and generics). EMS and transport usually carry this form.
• Premixed bag: 1,000 mg in 100 mL sodium chloride (10 mg/mL), single dose.
• Tablets: 650 mg, for heavy menstrual bleeding. This is not an emergency form.

Adult Dosing

Pediatric Dosing

Preparation & Administration

• Route: IV only. The 2025 NAEMSP/ACEP/ACS-COT joint statement accepts IO for prehospital trauma. Never give it spinal or epidural. Label every syringe and bag with the drug and the IV route.
• Rate: Trial and WHO regimen: 1 g over 10 min (100 mg/min). Label ceilings: undiluted 100 mg/mL no faster than 1 mL/min (Cyklokapron recommends 0.5 mL/min); premixed 1 g/100 mL bag no faster than 10 mL/min. Cyklokapron diluted by the user: 5 mL/min at 10 mg/mL or 2.5 mL/min at 20 mg/mL (50 mg/min). Faster injection can cause hypotension.
• Dilution: Give it undiluted, or dilute to 10 or 20 mg/mL in a compatible fluid (see Interactions & Compatibility). A diluted solution stays stable for 4 hr at room temperature.
• Maintenance infusion: 1 g over 8 hr (125 mg/hr) on an infusion pump; diluent and volume per institution.
• Do not mix: with blood or with penicillin-containing solutions.
• Inspect: Discard the vial if particulate matter is seen; discard any unused portion.

Contraindications

• Neuraxial injection: intrathecal or epidural administration (UK SmPC also: intraventricular injection and intracerebral application)
• Subarachnoid hemorrhage: risk of cerebral edema and infarction
• Active intravascular clotting (UK SmPC: acute venous or arterial thrombosis)
• Hypersensitivity to tranexamic acid or any ingredient
• Oral tablets only: combined hormonal contraception; active thromboembolic disease, or a history or intrinsic risk of thrombosis, including retinal vein or artery occlusion
• History of convulsions: The UK SmPC lists this as a contraindication, but the US label does not. In life-threatening hemorrhage, weigh it per medical direction.

Precautions

• Prior thrombosis or hypercoagulable state: Weigh this against the bleeding risk. WHO advises avoiding TXA in PPH when there is a clear contraindication, such as a known thromboembolic event during pregnancy.
• Renal impairment: It builds up and raises seizure risk. Adjust repeat doses (see Special Populations).
• Disseminated intravascular coagulation (DIC): In most cases, UK labeling says to avoid TXA.
• Upper urinary tract bleeding: Clots can block the urinary tract (UK labeling).
• Visual disturbance: If vision changes, stop TXA and arrange an eye examination.

Hold / Reassess If

• More than 3 hr since injury or birth: do not start
• Seizure: stop the infusion
• Hypotension during the bolus: slow or pause the injection
• New limb swelling, chest pain, hypoxia, focal deficit or vision loss: stop and evaluate for thrombosis

Common

• Nausea, vomiting, diarrhea
• Dizziness
• Hypotension: with rapid IV injection
• Allergic dermatitis
• Visual changes: blurred or altered color vision
• Frequencies are not established for emergency IV use. The data come from postmarketing reports.

Serious / Life-Threatening

Overdose & Toxicity Management

• Signs: nausea, vomiting, diarrhea; orthostatic hypotension; arterial or venous thrombosis; visual impairment, seizures, headache, mental status change; myoclonus; rash.
• Immediate management: stop TXA; supportive care; treat seizures and thrombosis per protocol.
• Antidote: none.

Clinically Significant Interactions

IV Compatibility

• Compatible: Most infusion solutions work, including electrolyte, carbohydrate, amino acid and dextran solutions. Heparin may be added.
• Incompatible: blood; penicillin-containing solutions.
• Stability: diluted solution up to 4 hr at 20–25°C (68–77°F).
• Verify with an institutional compatibility resource.

• Pediatrics: No pediatric efficacy trial has been completed. The evidence is small trials and observational studies, with mixed results. Prehospital pediatric TXA has not been studied, and no standard dose has been established. If it is used, give it within 3 hr of injury (2025 NAEMSP/ACEP/ACS-COT joint statement). See the Pediatric Dosing table.
• Neonates: Not established. Specialist use only.
• Pregnancy: It crosses the placenta, and cord levels are about equal to maternal levels. Published data have not shown a drug-associated risk of miscarriage or adverse maternal or fetal outcomes. It is recommended for PPH treatment. Per the WHO 2025 guideline, it is not recommended for routine PPH prevention at vaginal or cesarean birth.
• Lactation: It passes into breast milk at about one-hundredth of the maternal blood level (UK labeling). There are no data on effects in the breastfed infant. Weigh the benefit against the risk.
• Older Adults: Renal function is often reduced. Check creatinine before repeat dosing, and watch for thrombosis and seizures.
• Renal Impairment: Repeat and labeled IV dosing by serum creatinine: 1.36–2.83 mg/dL, 10 mg/kg twice daily; 2.83–5.66 mg/dL, 10 mg/kg once daily; >5.66 mg/dL, 10 mg/kg every 48 hr or 5 mg/kg every 24 hr. Oral: >1.4–2.8 mg/dL, 1,300 mg twice daily; >2.8–5.7 mg/dL, 1,300 mg once daily; >5.7 mg/dL, 650 mg once daily. Trauma and PPH trials used fixed 1 g doses without renal adjustment.
• Hepatic Impairment: No specific adjustment has been established. More than 95% is excreted unchanged in urine.
• Obesity / Dosing Weight: Trauma, TBI and PPH doses are fixed at 1 g. They are not weight-based. Labeled hemophilia dosing and pediatric doses use actual body weight.

• Scope: Paramedic and above, RN and critical-care transport. Use it for trauma with signs of hemorrhagic shock within 3 hr of injury, and for postpartum hemorrhage. Isolated traumatic brain injury (TBI) is not a routine field indication. The prehospital TBI trial did not show a benefit (favorable 6-month outcome 65% with TXA vs 62% with placebo, P=.16). CRASH-3 enrolled hospital patients (head-injury death 18.5% vs 19.8%, RR 0.94, 95% CI 0.86–1.02; RR 0.78 in mild-to-moderate TBI). Give TXA for TBI only on medical direction or in hospital. It varies by state and agency protocol.
• Storage & Stability: 20–25°C (68–77°F); excursions 15–30°C (59–86°F) permitted. Protect from vehicle heat and cold extremes.
• Carried Concentration: Carried as a 1,000 mg/10 mL (100 mg/mL) vial or ampule. Some services stock the 1,000 mg/100 mL premix. On labor and delivery and in the OR, keep TXA physically separate from bupivacaine and other spinal anesthetics.
• Time Window: Write down the time of injury or birth on scene. If hospital arrival will push past 3 hr, give it en route when protocol allows.
• Infusions in Transport: The 8-hr maintenance infusion (1 g at 125 mg/hr) runs on a pump. Verify the dose, start time and remaining volume at handoff.
• Handoff Essentials: Say clearly that TXA was given, with the dose(s), route and times, so the hospital does not repeat it. Include the time of injury or birth. Say whether the maintenance infusion has started, and report the BP response and any seizure or hypotension.

Mechanism of Action

• TXA is a synthetic lysine analog. It blocks the lysine-binding sites on plasminogen. Plasmin cannot bind to and degrade fibrin, so the existing clot is preserved.
• It stops clot breakdown. It does not form new clot. The thrombotic risk comes from tipping the balance away from fibrinolysis.
• Trauma and childbirth switch on early fibrinolysis. That is why the benefit depends on early dosing.
• At high exposure, the likely cause of seizures is antagonism of inhibitory GABA-A and glycine receptors in the central nervous system.

Pharmacokinetics

• Half-life: about 2 hr terminal elimination after 1 g IV (US label; UK labeling about 3 hr); mean terminal half-life about 11 hr after oral dosing.
• Metabolism: minimal.
• Elimination: renal, by glomerular filtration; more than 95% unchanged; about 90% excreted within 24 hr after IV dosing.
• Distribution: initial volume of distribution 9–12 L; protein binding about 3%; cerebrospinal fluid levels about one-tenth of plasma; oral bioavailability about 45%.

Generic Name

Tranexamic acid (TXA)

Brand Names

Cyklokapron (IV); Lysteda (oral); generic injection, premixed bags and tablets

Pharmacologic Class

Synthetic lysine analog antifibrinolytic

Therapeutic Class

Hemostatic agent

Controlled Substance

Not controlled

ISMP High-Alert

No

Look-Alike / Sound-Alike

Tranexamic acid vials and ampules / bupivacaine and other spinal anesthetics (wrong-route deaths)