The use of tranexamic acid in the management of injured patients at risk of hemorrhage: a systematic review and meta-analysis and an Eastern Association for the Surgery of Trauma Practice Management Guideline

Affiliations

Affiliation

¹ From the Division of Trauma, Bariatric and Acute Care Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine (R.P.D.), Houston; Division of Burn, Trauma, Acute and Critical Care Surgery, Department of Surgery at UT Southwestern Medical Center (B.E.S), Dallas, Texas; Division of Acute Care Surgery and Trauma, Kessler Trauma Center, University of Rochester Medical Center (M.A.V.), Rochester, New York; Division of Acute Care Surgery, Department of Surgery at Vanderbilt University Medical Center (R.D.A.), Nashville, Tennessee; Pittsburgh Trauma and Transfusion Medicine Research Center in the Department of Surgery at the University of Pittsburgh (M.D.N.), Pittsburgh, Pennsylvania; Division of Burn, Trauma, Acute and Critical Care Surgery, Department of Surgery at UT Southwestern Medical Center (L.A.D.), Dallas, Texas; Department of Emergency Medicine at Weill Cornell Medicine (K.H.S.), New York, New York; Division of Trauma, Burns, Critical Care, and Acute Care Surgery at the MetroHealth System (N.J.P.), Cleveland, Ohio; The Queen's Medical Center (A.M.B.), Honolulu, Hawaii; Division of General Surgery, Trauma and Surgical Critical Care, Department of Surgery, UCSF (L.Z.K.), San Francisco, California; Division of Trauma and Critical Care, Department of Surgery at the Medical College of Wisconsin (P.B.M.), Milwaukee, Wisconsin; Division of General, Acute Care, Trauma, and Burn Surgery, Department of Surgery at the Medical University of South Carolina (B.K.B.) Charleston, South Carolina; Conemaugh Memorial Medical Center (M.C.S.), Johnstown, Pennsylvania; Advocate Illinois Masonic Medical Center (I.M.), Chicago, Illinois; Cleveland Clinic (S.H.A.), Cleveland, Ohio; Department of Surgery (M.A.S.), Uniformed Services University, Bethesda, Maryland; Division of Trauma and Critical Care, Department of Surgery, University of Mississippi Medical Center (M.E.K.), Jackson, Mississippi; University of Pittsburg (J.L.S.), Pittsburgh, Pennsylvania; Department of Biostatistics, Epidemiology and Informatics, Penn Medicine (W.Y.), University of Pennsylvania, Philadelphia PA; Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Hospital of the University of Pennsylvania (J.C.C.), Philadelphia PA; and Division of Trauma and Acute Care Surgery, Los Angeles General Medical Center (M.J.M.), Los Angeles, California.

PMID: 40956301
DOI: 10.1097/TA.0000000000004773

The use of tranexamic acid in the management of injured patients at risk of hemorrhage: a systematic review and meta-analysis and an Eastern Association for the Surgery of Trauma Practice Management Guideline

Ryan P Dumas et al. J Trauma Acute Care Surg. 2025.

. 2025 Sep 15.

doi: 10.1097/TA.0000000000004773. Online ahead of print.

Affiliation

¹ From the Division of Trauma, Bariatric and Acute Care Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine (R.P.D.), Houston; Division of Burn, Trauma, Acute and Critical Care Surgery, Department of Surgery at UT Southwestern Medical Center (B.E.S), Dallas, Texas; Division of Acute Care Surgery and Trauma, Kessler Trauma Center, University of Rochester Medical Center (M.A.V.), Rochester, New York; Division of Acute Care Surgery, Department of Surgery at Vanderbilt University Medical Center (R.D.A.), Nashville, Tennessee; Pittsburgh Trauma and Transfusion Medicine Research Center in the Department of Surgery at the University of Pittsburgh (M.D.N.), Pittsburgh, Pennsylvania; Division of Burn, Trauma, Acute and Critical Care Surgery, Department of Surgery at UT Southwestern Medical Center (L.A.D.), Dallas, Texas; Department of Emergency Medicine at Weill Cornell Medicine (K.H.S.), New York, New York; Division of Trauma, Burns, Critical Care, and Acute Care Surgery at the MetroHealth System (N.J.P.), Cleveland, Ohio; The Queen's Medical Center (A.M.B.), Honolulu, Hawaii; Division of General Surgery, Trauma and Surgical Critical Care, Department of Surgery, UCSF (L.Z.K.), San Francisco, California; Division of Trauma and Critical Care, Department of Surgery at the Medical College of Wisconsin (P.B.M.), Milwaukee, Wisconsin; Division of General, Acute Care, Trauma, and Burn Surgery, Department of Surgery at the Medical University of South Carolina (B.K.B.) Charleston, South Carolina; Conemaugh Memorial Medical Center (M.C.S.), Johnstown, Pennsylvania; Advocate Illinois Masonic Medical Center (I.M.), Chicago, Illinois; Cleveland Clinic (S.H.A.), Cleveland, Ohio; Department of Surgery (M.A.S.), Uniformed Services University, Bethesda, Maryland; Division of Trauma and Critical Care, Department of Surgery, University of Mississippi Medical Center (M.E.K.), Jackson, Mississippi; University of Pittsburg (J.L.S.), Pittsburgh, Pennsylvania; Department of Biostatistics, Epidemiology and Informatics, Penn Medicine (W.Y.), University of Pennsylvania, Philadelphia PA; Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Hospital of the University of Pennsylvania (J.C.C.), Philadelphia PA; and Division of Trauma and Acute Care Surgery, Los Angeles General Medical Center (M.J.M.), Los Angeles, California.

PMID: 40956301
DOI: 10.1097/TA.0000000000004773

Abstract

Background: The use of tranexamic acid in trauma patients at risk for hemorrhage remains controversial. This guideline evaluates the use of tranexamic acid in two clinical settings, the prehospital environment and the inpatient setting. In addition, this PMG evaluates the use TXA in specific populations and at different dosages and evaluates the potential risks associated with its use.

Methods: Using the Grading of Recommendations Assessment, Development and Evaluation methodology, an EAST working group conducted a systematic review using MEDLINE, EMBASE, and COCHRANE CENTRAL. Articles in English from 2000 through 2023 were considered in evaluating four PICO questions relevant to the use of TXA in injured trauma patients at risk of hemorrhage (defined as patients with a systolic blood pressure (SBP) ≤90 mm Hg or a heart rate ≥110/min or suspicion for active hemorrhage).

Results: Thirty studies were identified for qualitative analysis, of which 24 met criteria for meta-analysis. TXA was associated with a significant reduction in 24-hour mortality in both prehospital (log risk ratio, -0.29; 95% confidence interval, -0.53 to -0.05; p = 0.02) and in-hospital settings (-0.38[-0.69, -0.06]; p = 0.02). A similar benefit was observed at 30-days across both settings (prehospital: -0.18[-0.35, -0.00]; p = 0.05, in-hospital: -0.24[-0.40, -0.07]; p = 0.01). In patients with SBP ≤75 mm Hg, TXA reduced mortality, but this was not found to be significant (-0.18 [-0.46, 0.09]; p = 0.20). The incidence of vaso-occlusive events did not differ between groups in either setting. Moreover, a large heterogeneity regarding TXA dosing regimens and comparison groups across studies was observed.

Conclusion: Based on current available evidence, we conditionally recommend for the routine use of TXA in the prehospital and in-hospital settings. We cannot recommend for or against the use of an initial higher dose of bolus TXA. Finally, we conditionally recommend for the routine use of TXA in patients with severe hypotension.

Level of evidence: Level 1: Meta-analysis.

Keywords: TXA; blood; hemorrhage; resuscitation; tranexamic acid.

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References

1. Cai J, Ribkoff J, Olson S, Raghunathan V, Al-Samkari H, DeLoughery TG, et al. The many roles of tranexamic acid: an overview of the clinical indications for TXA in medical and surgical patients. Eur J Haematol. 2020;104(2):79–87.
1. Hunt BJ. The current place of tranexamic acid in the management of bleeding. Anaesthesia. 2015;70(Suppl 1):50–3, e18.
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1. Franchini M, Mannucci PM. Adjunct agents for bleeding. Curr Opin Hematol. 2014;21(6):503–508.
1. Cole E, Davenport R, Willett K, Brohi K. Tranexamic acid use in severely injured civilian patients and the effects on outcomes: a prospective cohort study. Ann Surg. 2015;261(2):390–394.

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The use of tranexamic acid in the management of injured patients at risk of hemorrhage: a systematic review and meta-analysis and an Eastern Association for the Surgery of Trauma Practice Management Guideline

Affiliation

The use of tranexamic acid in the management of injured patients at risk of hemorrhage: a systematic review and meta-analysis and an Eastern Association for the Surgery of Trauma Practice Management Guideline

Authors

Affiliation

Abstract

References

LinkOut - more resources

Full Text Sources

Research Materials

Miscellaneous