In patients with moderate traumatic brain injury (TBI) (Glasgow Coma Scale greater than 8 and less than 13) presenting within three hours of injury, immediately administer tranexamic acid (Grade 1B).

In the CRASH-3 trial, among 9000 patients presenting within three hours of TBI with a Glasgow Coma Scale (GCS) <13 or any evidence of intracranial bleeding on CT scan, those receiving tranexamic acid had a risk of head injury-related death that was non-significantly lower relative to placebo. This difference was statistically significant when patients with unreactive pupils were excluded and in the subgroup of patients with mild to moderate TBI.

Tranexamic acid may also be considered in other patient groups, such as those with severe TBI and reactive pupils or those with mild TBI (GCS >12) and intracranial bleeding; however, a benefit is less certain in these patients. 

 Reference: CRASH-3 trial collaborators. Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH-3): a randomised, placebo-controlled trial. Lancet 2019; 394:1713.

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA