Tranexamic Acid Administration in Traumatic Brain Injury

Patient Selection and Treatment Protocol

The Association of Anaesthetists recommends that tranexamic acid should be administered in patients with traumatic brain injury, particularly those with mild-to-moderate TBI, using a 1-g loading dose over 10 minutes followed by 1-g infusion over 8 hours, initiated as early as possible and within 3 hours of injury 1, 2
The European Society of Intensive Care Medicine provides a conditional recommendation for TXA use in TBI patients, acknowledging that while TXA does not reduce all-cause mortality across all TBI severities, it may reduce head-injury associated death in specific populations 3, 4
Appropriate candidates for TXA include patients with mild-to-moderate TBI (GCS >3), patients without bilateral unreactive pupils at baseline, and patients presenting within 3 hours of injury 1, 2, 3, 4
The standard regimen for TXA administration is a loading dose of 1 g IV over 10 minutes, followed by 1 g IV over 8 hours, administered as soon as possible, ideally within 3 hours of injury 1, 2, 3, 4

No significant increase in vascular occlusive events (stroke, MI, venous thromboembolism) has been observed with TXA administration 3, 4
The risk of seizures is similar to placebo (RR 1.09, 95% CI 0.90-1.33) 3, 4
Higher doses may increase seizure risk in other populations (cardiac surgery), but standard TBI dosing appears safe 5

Administer TXA empirically before viscoelastic testing results, as point-of-care measurements have varying sensitivity for hyperfibrinolysis 3, 4
Early empiric use is more important than waiting for laboratory confirmation 3, 4
Delaying administration beyond 3 hours significantly reduces effectiveness and may increase mortality 5
Withholding TXA in severe TBI is not recommended, as patients often have mixed injury patterns requiring assessment; early administration is reasonable in polytrauma 3, 4