Bolus-Only Versus Bolus-Plus-Infusion Tranexamic Acid for Trauma: A Propensity Score-Matched Study

The CRASH-2 regimen for tranexamic acid (TXA) consists of a 1-g intravenous bolus followed by a 1-g infusion over 8 hours. The maintenance infusion may be challenging to administer during the early phase of trauma resuscitation. We compared mortality outcomes between patients receiving a 1-g TXA bolus alone and those receiving a bolus-plus-infusion regimen.

We conducted a retrospective cohort study of adult trauma patients (≥ 19 years) who presented directly to the trauma bay at a regional trauma center between July 2018 and December 2023. Patients who received TXA within 3 hours of injury were included in the inter-regimen analysis and categorized into either a 1-g bolus-only group or a 1-g bolus plus 1-g infusion group. Clinical outcomes were compared using multivariable logistic regression. To minimize selection bias and baseline imbalances, 1:1 propensity score matching was performed, followed by McNemar testing and conditional logistic regression analyses in the matched cohort.

Among 5204 eligible patients, 1787 received TXA. The primary inter-regimen cohort included 1408 patients treated within 3 hours of injury: 409 received bolus-only TXA and 999 received bolus-plus-infusion TXA. Propensity score matching yielded 335 pairs. After matching, mortality did not differ significantly between the groups: in-hospital mortality 14.0% versus 17.3% (adjusted odds ratio [aOR], 1.29; 95% confidence interval [CI], 0.84-1.97; p = 0.240), 24-h mortality 4.5% versus 5.1% (aOR, 1.13; 95% CI, 0.57-2.27; p = 0.724), and 28-day mortality 9.3% versus 11.9% (aOR, 1.36; 95% CI, 0.81-2.28; p = 0.243).

In this single-center retrospective cohort study, a 1-g TXA bolus alone was associated with mortality outcomes comparable to those of the conventional bolus-plus-infusion regimen among patients treated within 3 hours of injury. Prospective studies are warranted to validate these findings.