Opportunities to expand delivery of prehospital tranexamic acid to bleeding trauma patients – findings from a prospective multicentre trauma study in the Western Cape Province, South Africa

Background. Traumatic haemorrhage is a leading cause of preventable injury-related deaths. Tranexamic acid (TXA) has demonstrated a 38% all-cause mortality reduction when administered to severe haemorrhagic shock patients in South Africa (SA). Yet its prehospital utilisation in SA remains limited owing to prehospital provider qualification restrictions, despite the region’s high trauma burden. Among the 4% of prehospital providers licensed to administer TXA, prehospital eligibility and TXA administration is poorly reported. This utilisation gap suggests multifactorial barriers beyond the current scope of practice restrictions that impede effective implementation of this evidence-based intervention. Objective. To assess patterns of TXA administration and omission during prehospital emergency care in the Western Cape Province, SA. Methods. This is a secondary analysis from the EpiC prospective multicentre study. The current study examined 4 094 patients at risk of haemorrhage in the Western Cape from August 2021 to December 2024. First, we assessed patient and injury characteristics as well as prehospital and hospital treatments among three prehospital treatment groups: those who received TXA; those who received a lifesaving circulation intervention and no TXA; and those who received neither. Second, a subset of patients was selected for three clinical scenarios: patients with moderate to severe risk of shock; those with severe shock meeting TXA eligibility criteria; and those requiring hospital-based interventions for haemorrhage. Prehospital provider qualifications, clinical interventions and outcomes were assessed using descriptive statistics, and Sankey diagrams were used to visually depict the quantity and flow of prehospital trauma patients stratified by prehospital provider qualification. Results. Only 2.8% (n=116) of all haemorrhage-risk patients received prehospital TXA despite 82% (n=3 325) presenting within the 3-hour window for administration. Among eligible patients with severe risk of shock who were managed by an advanced prehospital provider (n=161), only 19% (n=30) received TXA. Basic and intermediate prehospital providers, who cannot administer TXA under current regulations, managed 67% (n=326) of these patients. These providers frequently delivered other life-saving circulatory interventions (70 - 79%). Conclusion. This study reveals that only a small percentage of eligible trauma patients receive TXA despite its established mortality benefit. The principal barrier identified is the current scope-of-practice restriction preventing basic and intermediate prehospital providers from administering TXA, despite managing two-thirds of eligible patients and possessing the knowledge and skills to deliver TXA. We strongly recommend that the scope of TXA be extended to intermediate prehospital providers in SA.