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Antifibrinolytic Pregnancy: Use in life-threatening obstetric haemorrhage — WOMAN trial supports use; benefits outweigh risks

Tranexamic Acid (ICU/Trauma/Surgical)

Brand names: Cyklokapron, Cyklo-f

Adult dose

Dose: Trauma haemorrhage: 1 g IV over 10 min then 1 g over 8 hours (must give within 3 hours of injury); Major surgery: 15–30 mg/kg IV; Cardiac surgery: 10–30 mg/kg loading + infusion
Route: IV
Frequency: Loading dose then maintenance as per protocol
Max: 6 g/day
Inhibits plasminogen activation → prevents fibrin clot breakdown → reduces haemorrhage. CRASH-2 trial: must give within 3 hours of trauma — after 3 hours increases mortality.

Paediatric dose

Dose: 15–20 mg/kg
Route: IV
Frequency: Loading dose then maintenance
Max: 1 g per dose
Paediatric trauma/surgical haemorrhage: 15–20 mg/kg loading over 10 min then 2–10 mg/kg/hour infusion under specialist guidance.

Dose adjustments

Renal

Reduce dose significantly in renal impairment — accumulates. Creatinine 120–249 µmol/L: 10 mg/kg BD; 250–500 µmol/L: 5 mg/kg OD; >500 µmol/L: 2.5 mg/kg OD.

Hepatic

No specific adjustment required.

Paediatric weight-based calculator

Paediatric trauma/surgical haemorrhage: 15–20 mg/kg loading over 10 min then 2–10 mg/kg/hour infusion under specialist guidance.

Clinical pearls

  • CRASH-2 trial (NEJM 2010): TXA within 3 hours of trauma reduced all-cause mortality — after 3 hours, mortality INCREASED. Time window is critical.
  • WOMAN trial (2017): TXA reduced death from postpartum haemorrhage when given within 3 hours of delivery
  • CRASH-3 trial (2019): TXA in mild-moderate TBI within 3 hours reduced head injury deaths — recommended in major trauma protocols
  • Intrathecal/intraventricular TXA is absolutely contraindicated — causes catastrophic seizures

Contraindications

  • Active thromboembolic disease (DVT, PE, MI, stroke)
  • Subarachnoid haemorrhage (increases cerebral ischaemia risk with seizure provocation)
  • Haematuria of upper urinary tract origin (clot retention risk)
  • Disseminated intravascular coagulation (DIC) without adequate anticoagulation

Side effects

  • Nausea/vomiting (rapid IV)
  • Hypotension (rapid infusion)
  • Seizures (high doses — especially intrathecal/intraventricular use)
  • Thromboembolic events (DVT, PE)
  • Visual disturbance (prolonged use)

Interactions

  • Combined oral contraceptives (additive thrombotic risk)
  • Factor IX complex concentrates (additive thrombosis risk)

Monitoring

  • Haemorrhage control (blood loss, Hb, coagulation screen)
  • Signs of thromboembolism
  • Renal function (dose adjustment)

Reference: BNFc; BNF 90; CRASH-2 Trial (Lancet 2010); WOMAN Trial (Lancet 2017); CRASH-3 Trial (Lancet 2019); BNFc. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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