ABSTRACT 
Prehospital use of tranexamic acid (TXA) has grown substantially over the past decade despite
contradictory evidence supporting its widespread use. Since the previous guidance document on
The prehospital use of TXA for injured patients was published by the National Association of
Emergency Medical Services Physicians (NAEMSP), the American College of Surgeons Committee on
Trauma (ACS-COT), and the American College of Emergency Physicians (ACEP) in 2016, new research
has investigated outcomes of patients who receive TXA in the prehospital setting. To provide
updated evidence-based guidance on the use of intravenous TXA for injured patients in the EMS
setting, we performed a structured literature review and developed the following recommendations
supported by the evidence summarized in the accompanying resource document.
NAEMSP, ACEP, AND ACS-COT RECOMMENDS
• Prehospital TXA administration may reduce mortality in adult trauma patients with hemorrhagic
shock when administered after lifesaving interventions.
• Prehospital TXA administration appears safe, with low risk of thromboembolic events or
seizure.
• The ideal dose, rate, and route of prehospital administration of TXA for adult trauma patients
with hemorrhagic shock has not been determined. Current evidence suggest EMS agencies
may administer either a 1-gram IV/IO dose (followed by a hospital-based 1-gram infusion
over 8 hours), or a 2-gram IV/IO dose as an infusion or slow push.
• Prehospital TXA administration, if used for adult trauma patients, should be given to those
with clinical signs of hemorrhagic shock and no later than 3hours post-injury. There is no
evidence to date to suggest improved clinical outcomes from TXA initiation beyond this time
or in those without clinically significant bleeding.
• The role of prehospital TXA in pediatric trauma patients with clinical signs of hemorrhagic
shock has not been studied and standardized dosing has not been established. If used, it
should be given within 3 hours of injury.
• Prehospital TXA administration, if used, should be clearly communicated to receiving healthcare
professionals to promote appropriate monitoring and to avoid duplicate administration(s).
• A multidisciplinary team, led by EMS physicians, that includes EMS clinicians, emergency
physicians, and trauma surgeons should be responsible for developing a quality improvement
program to assess prehospital TXA administration for protocol compliance and identification
of clinical complications
