Prehospital tranexamic acid bolus improves outcomes in traumatic brain injury: A Bayesian reanalysis of the prehospital TXA for TBI trial.

BACKGROUND

Despite two large randomized controlled trials (RCT) designed to assess tranexamic acid (TXA) for traumatic brain injury (TBI) patients, its use and optimal dosing strategy in TBI remains uncertain. We sought to assess functional and mortality outcomes associated with prehospital TXA administration for TBI patients using Bayesian techniques.

METHODS

We performed a post hoc analysis of the prehospital TXA for TBI RCT where TBI patients received TXA as a 1-g bolus followed by a 1-g infusion (standard), 2-g bolus (bolus), or placebo. Bayesian regression models were created to assess the association of early prehospital TXA administration in TBI patients using posterior probabilities for 6-month functional outcomes, as well as 28-day and 6-month mortality.

RESULTS

Patients receiving prehospital TXA (standard or bolus) displayed a 78.1% probability of having improved functional neurologic outcomes at 6 months compared with placebo. When compared with placebo, the Bolus cohort displayed a 95.3% probability of improved functional neurologic outcomes at 6 months, a 95.3% probability of decreased mortality at 28 days, and a 70.7% probability of decreased mortality at 6 months. The Standard cohort displayed a less than 50% probability of benefit compared with placebo for all outcomes measured.

CONCLUSION

A prehospital 2 g TXA bolus dosing strategy demonstrated a high probability of benefit compared with both placebo and Standard cohorts for functional neurologic and mortality outcomes in patients with moderate to severe TBI. ( J Trauma Acute Care Surg . 2026;100: 879-885. © 2026 American Association for the Surgery of Trauma.).

LEVEL OF EVIDENCE: Therapeutic; Level III.