Tranexamic Acid

The CRASH-2 trial showed that tranexamic acid (TXA) administration reduces mortality in bleeding trauma patients. However, the effect appeared to depend on how soon after injury TXA treatment was started. Treatment within 3 h reduced bleeding deaths whereas treatment after 3 h increased the risk.

  • Trauma patients who are bleeding or at risk of significant hemorrhaging as early as possible (GRADE 1A) and to bleeding trauma patients within 3 h after an injury (GRADE 1B).

  • TXA may be administered IV/IM/PO

  • 1000 mg IM/IV = 1950 mg PO

  • The HCVI/MOAS protocol is to administer an oral dose of 1950 mg (650 mg x 3) as soon as possible with a sip of water if IV access has not already been established.

  • If IV access is immediately available, an IV dose of 1000 mg is preferred.

  • Typically a second dose of 1000 mg is given once IV access has been established.

  • Due to the large volume involved, IM injection is the least preferred option in the acute battlefield trauma situation.

    • If administered IM, give a split dose*


  • TXA is also being used in the preoperative setting to reduce intraoperative bleeding and well as in the management of intracranial hemorrhage.

  • It is commonly used around the globe by women to control heavy menstrual bleeding (1300 mg 2-3 times daily is the typical dose; concern regarding potential increased VTE risk when combined with oral contraceptive (OCP) appears to be more theoretical than practical based upon large observational studies and combined use is regarded as safe).


  • The ventrogluteal region (targeting the gluteus medius1,16) and the vastus lateralis region are free of major nerves and blood vessels.3,17,18 The safety of the ventrogluteal region as an area for administering IM injections is established and the area is identified as a preferred site within clinical practice guidelines.1,3,12,16-18,20

  • IM injections also may be beneficial for absorption compared with other routes of administration (ie, faster than subcutaneous injection and slower than intravenous administration). In addition, some medications contain components that can irritate subcutaneous tissue but not muscle tissue, which also can tolerate larger fluid volumes with minimal discomfort.3,4

  • Medications administered via large-volume IM injections include ceftazidime (Fortaz, Tazicef, generics), cefuroxime (Ceftin, Zinacef, generics), ertapenem (Invanz), penicillin G benzathine (Bicillin L-A, Permapen), and fulvestrant (Faslodex).5-9


The Z-track method, historically applied to IM injections of irritating medications, can be used for all IM injections to reduce pain and prevent dispersion of medication into subcutaneous tissue