678-366-7933
Product Library
Tranexamic Acid for Management of Acute Hemorrhage in Pediatric Patients in the Emergency Department
What ED Clinicians Need to Know
Tranexamic acid (TXA) is an antifibrinolytic medication that has become a versatile, low-cost tool for temporizing acute hemorrhage in children across a broad range of clinical scenarios. This issue reviews the evidence for TXA in traumatic hemorrhage, traumatic brain injury, posttonsillectomy bleeding, epistaxis, oral and gingival bleeding, lower airway bleeding, and traumatic hyphema, with a focus on ED decision-making, the available routes of administration, and the safety profile.
While the pediatric evidence is more limited than the adult literature, TXA stabilizes clots rather than initiating clotting and has shown a strong safety record in the studies reviewed. The issue emphasizes practical considerations for emergency clinicians, including how to match the route of administration to the bleeding scenario and the developmental stage of the child, when systemic versus topical delivery is appropriate, and the common pitfalls and adverse effects to keep in mind.
Why This Topic Matters in the ED
- Acute hemorrhage in children spans many presentations (trauma, nosebleeds, posttonsillectomy bleeding, etc) and TXA offers a single, adaptable option across all of them.
- TXA can be delivered through multiple systemic and topical routes, giving clinicians flexibility when IV access is difficult or when a less invasive approach is more appropriate.
- Clinicians may be unfamiliar with TXA dosing, preparation, and safety, which can lead to inconsistent use; clear guidance supports more confident, timely treatment.
- Understanding when TXA helps, and when it may not or could be harmful, supports better critical decision-making and helps avoid common pitfalls.
Clinical Content at a Glance
Clinical Q&A
- What are the indications for TXA in pediatric acute hemorrhage?
- TXA has been studied across a range of bleeding scenarios in children, including traumatic hemorrhage, posttonsillectomy bleeding, epistaxis, oral and gingival bleeding, lower airway bleeding, and traumatic hyphema. The strength of the evidence varies by scenario.
- What routes of administration are available?
- TXA can be given systemically (including oral, intravenous, intraosseous, and intramuscular) or topically (including oral rinse, paste, soaked products, nebulized, and atomized). The best route depends on the bleeding source and the individual patient.
- How does timing affect TXA administration in trauma?
- In trauma, the benefit of systemic TXA is time-sensitive, and there is an evidence-supported window after injury within which it should be given. Administration outside that window may not help and may be harmful.
- What are the potential adverse effects of TXA?
- TXA is generally well tolerated in the reviewed studies, but clinicians should be aware of uncommon events such as hypersensitivity reactions and seizures, in addition to standard FDA-listed cautions and contraindications.
- Does TXA increase the risk for blood clots?
- TXA is an antifibrinolytic that stabilizes existing clots. It is not a procoagulant. Multiple studies in adults and children have not shown an increased rate of thromboembolic events with TXA treatment, though systemic use is contraindicated in active thrombotic disease.
Case Snapshots
Case 1 — Pediatric Trauma With Hemorrhagic Shock: A 16-year-old boy struck by a car presents with abdominal injury and signs of hemorrhagic shock during massive transfusion. The issue walks through whether and when systemic TXA fits into the resuscitation and how timing from injury shapes that decision.
Case 2 — Posttonsillectomy Bleeding: A 4-year-old girl returns with bleeding several days after tonsillectomy, and ice-water gargling is not developmentally feasible. The issue explores developmentally appropriate, less invasive methods to temporize the bleeding while specialty care is arranged.
Case 3 — Refractory Epistaxis: A 7-year-old boy has a persistent nosebleed that has not responded to first-line measures. The issue considers topical TXA options that may be tried before moving to more invasive procedures such as cautery.
Clinical Tools
- Overview of TXA delivery methods and routes of administration
- Summary of TXA administration strategies for posttonsillectomy bleeding across published studies
- Summary of TXA administration strategies for oral and gingival bleeding
- Summary of nebulized TXA strategies for lower airway bleeding across published studies
- Reference table of contraindications and potential adverse effects of TXA
- Clinical pathway for the use of TXA in pediatric acute hemorrhage in the ED
Risk Management Pitfalls
- Giving TXA to trauma patients outside the evidence-supported time window from injury
- Withholding TXA over unfounded concerns that it will cause blood clots
- Not using versatile formulations of TXA when a preferred preparation is unavailable
- Focusing only on thromboembolic risk and overlooking other adverse effects such as seizure and hypersensitivity
- Moving to invasive procedures for epistaxis before considering topical TXA
Key References
Following are the most informative references cited in this paper, as determined by the authors.
2. * Wang K, Santiago R. Tranexamic acid - a narrative review for the emergency medicine clinician. Am J Emerg Med. 2022;56:33-44. (Review) DOI: https://doi.org/10.1016/j.ajem.2022.03.027
9. * Roberts I, Shakur H, Coats T, et al. The CRASH-2 trial: a randomised 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. (Randomized controlled trial; 20,211 patients) DOI: https://doi.org/10.3310/hta17100
10. * Roberts I, Shakur-Still H, Aeron-Thomas A, et al. Tranexamic acid to reduce head injury death in people with traumatic brain injury: the CRASH-3 international RCT. Health Technol Assess. 2021;25(26):1-76. (Randomized controlled trial; 9127 patients) DOI: https://doi.org/10.3310/hta25260
11. * WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet. 2017;389(10084):2105-2116. (Randomized controlled trial; 20,060 patients) DOI: https://doi.org/10.1016/S0140-6736(17)30638-4
42. * Spinella PC, Leonard JC, Gaines BA, et al. Use of antifibrinolytics in pediatric life-threatening hemorrhage: a prospective observational multicenter study. Crit Care Med. 2022;50(4):e382-e392. (Prospective cohort study; 449 patients) DOI: https://doi.org/10.1097/CCM.0000000000005383
CME Information
- 4 CME credits (available for subscribers)
- Includes Pharmacology
- View complete CME Information here
