Tranexamic acid is associated with post-injury mortality in a resource-limited trauma system: Findings from the epidemiology and outcomes of prolonged trauma care cohort study

Transfusion. 2025 May;65 Suppl 1(Suppl 1):S276-S287. doi: 10.1111/trf.18171. Epub 2025 Feb 28.

Abstract

Background: Injury-related deaths claim millions of lives annually, with severe hemorrhage a leading cause. This study assesses tranexamic acid (TXA) administered within 3 h post-injury on mortality in trauma patients.

Study design and methods: We conducted secondary database analysis of EpiC, a multicenter, prospective cohort of trauma patients in South Africa. We compared mortality between severely injured patients at risk for traumatic hemorrhage receiving TXA within 3 h post-injury versus untreated patients. Inverse probability of treatment weighting adjusted for confounders, and multivariate logistic regression assessed 24-h mortality, with extended secondary outcome analyses.

Results: Of 3607 analyzed patients, 502 received TXA within 3 h. TXA reduced 24-h mortality by 38% (marginal odds ratio [mOR], 0.62; 95% confidence interval [CI], 0.49-0.78) versus untreated patients. Similar reductions were observed for longer-term mortality. Subgroup analyses revealed reduced mortality when TXA was given within 2 h post-injury (mOR, 0.57; 95% CI, 0.45-0.73), doses of 1 g of TXA within 3 h (mOR, 0.73; 95% CI, 0.56-0.94), and those with the highest risk of hemorrhage (mOR, 0.40; 95% CI, 0.30-0.53). The 24-h mortality reduction was significant for patients with penetrating injury (mOR, 0.58; 95% CI, 0.43-0.78) but not for blunt injury patients. Sensitivity analyses confirmed the robustness of these findings, with TXA consistently reducing mortality odds by 28%-39% across subgroups.

Discussion: Early TXA administration significantly reduced mortality in trauma patients, especially with penetrating injuries and those with the highest risk of hemorrhage. One-gram dosing was as effective as higher doses, and mortality reduction was notable when TXA was given within 2 h post-injury. These findings support TXA use in resource-limited trauma protocols.

Keywords: emergency medicine; global health; hemorrhage; military medicine; tranexamic acid; trauma.

Publication types

  • Comparative Study

MeSH terms

  • Adult
  • Antifibrinolytic Agents* / administration & dosage
  • Antifibrinolytic Agents* / therapeutic use
  • Cohort Studies
  • Female
  • Hemorrhage* / drug therapy
  • Hemorrhage* / etiology
  • Hemorrhage* / mortality
  • Humans
  • Male
  • Middle Aged
  • Multicenter Studies as Topic
  • Observational Studies as Topic
  • Prospective Studies
  • Secondary Data Analysis
  • South Africa / epidemiology
  • Tranexamic Acid* / administration & dosage
  • Tranexamic Acid* / therapeutic use
  • Trauma Centers
  • Wounds and Injuries* / complications
  • Wounds and Injuries* / drug therapy
  • Wounds and Injuries* / mortality

Substances

  • Antifibrinolytic Agents
  • Tranexamic Acid