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TXA in Trauma: What You Need to Know from the New Joint Position Statement (2025)

In August 2025, a major joint position statement was released by NAEMSP, ACEP, and the ACS Committee on Trauma regarding tranexamic acid (TXA) use in trauma care. The CRASH-2 and MATTERs trials first hinted at this benefit, but this 2025 joint statement unites the major U.S. bodies under one standard. This represents one of the most unified and significant updates to prehospital hemorrhage management in recent years. Here’s what every EMS clinician should know.


1. TXA is Beneficial – but Only if Timely and Appropriate


The new consensus highlights that TXA reduces mortality when administered to trauma patients with hemorrhagic shock, provided it is given within 3 hours of injury. The earlier, the better.


However, the statement emphasizes that TXA should only be given after life-saving priorities such as airway management, hemorrhage control, and rapid transport are underway.


2. Two Acceptable Dosing Strategies

TXA Administration in Pre-Hospital Settings

The statement recognizes two effective dosing options for EMS:


Traditional regimen: 1 g IV/IO bolus followed by a 1 g infusion over 8 hours.

Simplified regimen: A single 2 g IV/IO dose, given as a slow push or short infusion.


Both regimens are now acceptable, giving systems flexibility depending on logistics, resources, and transport times.


3. TXA is Adjunctive, Not Definitive


The authors stress that TXA is not a substitute for hemorrhage control. Direct pressure, tourniquets, hemostatic dressings, and rapid transport to a trauma center remain paramount. TXA is a supportive tool, not a magic bullet.


4. EMS Implementation Matters


For agencies, this update is a call to:


  • Update protocols to reflect the new evidence.

  • Train crews on indications, contraindications, and dosing flexibility.

  • Stock appropriately and ensure TXA is readily available for rapid deployment.


5. TXA Contraindications


Children Under 15 - We don’t routinely give TXA to children under 15 because the big trauma trials (like CRASH-2 and CRASH-3) excluded pediatric patients, so the evidence for benefit just isn’t there. Kids also have different clotting physiology and drug handling than adults, which makes simple weight-based extrapolation less reliable. TXA is widely used in pediatric surgery, but in trauma care it remains off-label and most EMS protocols avoid it until more pediatric-specific data is available.


Isolated Traumatic Brain Injury (TBI) - The key word here is isolated. Meaning if you suspect your patient has a brain bleed and no other uncontrolled hemorrhaging, you should avoid the use of TXA. To be clear, if you have patient with multi-system trauma, where a TBI is one of several injures, you may wish to consider the use of TXA.


Isolated Spinal Cord Injury - Much like an isolated TBI, you should not use TXA on patients who have a suspected isolated spinal cord injury without other signs of uncontrollable trauma.


Controlled Extremity Trauma - Patients who have a traumatic injury to only an extremity, that is controlled through either direct pressure or the application of tourniquets, are not considered candidates for TXA.

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Why This Matters for You


TXA isn’t new, but this joint position statement solidifies its place in the EMS toolbox with strong consensus. For medics, the takeaway is clear: if your trauma patient is in hemorrhagic shock, TXA should be part of your resuscitation plan—as soon as the basics are secured.


To Do List: Update your protocol(s). Update your mindset. TXA isn’t optional anymore—it’s a standard tool in hemorrhage control.


References

  1. CRASH-2 trial collaborators. "The CRASH-2 trial: a randomized controlled trial and economic evaluation of the effects of tranexamic acid on death, vascular occlusive events and transfusion requirement in bleeding trauma patients." Health Technol Assess. 2013;17(10):1–79. doi:10.3310/hta17100. PubMed


  2. CRASH-3 trial collaborators. "Effects of tranexamic acid on death, disability, vascular occlusive events, and other morbidities in patients with traumatic brain injury (CRASH-3): a randomised, placebo-controlled trial."


  3. Lancet. 2019;394(10210):1713–1723. doi:10.1016/S0140-6736(19)32233-0. The Lancet


  4. Roberts I, Shakur H, Afolabi A, et al. "The importance of early treatment with tranexamic acid in bleeding: an exploration of the time-dependent effect of treatment on mortality." Lancet. 2011;377(9771):1096–1101. doi:10.1016/S0140-6736(11)60278-X. ScienceDirect


  5. Gayet-Ageron A, Ker K, Shakur H, et al. "Exploration of the CRASH-2 trial: a multicenter, randomized, placebo-controlled trial of tranexamic acid in bleeding trauma patients: time-dependent effect of tranexamic acid on mortality." Trials. 2013;14:174. doi:10.1186/1745-6215-14-174. Trials Journal


  6. EMRA. "Does TXA MATTER When Your Patients CRASH?" EM Resident. Published 2020. EMRA.org


  7. London School of Hygiene & Tropical Medicine. "CRASH-3 Trial Results." Published 2019. CRASH-3 Blog






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