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
Abdullah et al. · South African Medical Journal · 2026
Prospective cohort · Secondary analysis · n = 4 094
Trauma · TXA · South Africa · Scope of practice
Written by: Pat Leighton
● Large sample ● Prospective data ● Multicentre ● Secondary analysis ● Observational only ● Single province
Despite strong evidence that TXA saves lives in trauma, fewer than 3% of eligible patients in the Western Cape received it prehospitally; largely because the providers managing most of our serious trauma calls aren’t permitted to give it.
Tranexamic acid (TXA) is an antifibrinolytic drug that helps stabilise blood clots and reduce bleeding. A previous South African study showed a 38% reduction in all-cause mortality when TXA was given within 3 hours of injury, making the prehospital window critical.
This study drew on the EpiC cohort — a large dataset tracking trauma patients across six Western Cape facilities between 2021 and 2024. The researchers identified 4 094 patients at risk of serious bleeding and examined who received TXA, who received other interventions instead, and who received nothing, broken down by the qualification level of the attending EMS provider.
Current guidelines dictate that only ALS providers (4% of the national EMS workforce) are currently authorised to administer TXA.
of at-risk patients received prehospital TXA
EMS arrived within the 3-hour treatment window
of eligible patients managed by providers who cannot give TXA
of eligible patients managed by advanced providers received TXA
Intermediate providers cared for the majority of seriously injured patients across all three clinical scenarios tested. They administered other life-saving interventions to 70–79% of their patients, demonstrating active clinical engagement. Current scope of practice limitations prevented any TXA delivery from this tier.
Notably, even advanced providers gave TXA to fewer than 1 in 5 eligible patients, suggesting barriers which may include high call volumes, documentation gaps, and clinical habit.
Prehospital interventions by provider tier
| Provider tier | Received TXA | Other intervention, no TXA | Neither |
|---|---|---|---|
| Advanced (ALS / ECP) | 9% | 66% | 25% |
| Intermediate (AEA / ECT) | 0% | 50% | 50% |
| Basic (BAA) | 0% | 28% | 72% |
Prehospital interventions by provider tier across all haemorrhage-risk patients (n = 4 094)
This is the first study to formally describe TXA eligibility and administration in the South African prehospital setting. The central finding that ILS providers are managing the majority of these patients, and are authorised to give other life-saving drugs such as adrenaline, midazolam, and magnesium sulphate, but not TXA, reveals a regulatory inconsistency that the authors convincingly argue should be addressed. Extending TXA authorisation to AEAs and ECTs could, by the authors’ estimate, reach more than two-thirds of currently eligible patients who are being missed. Given the established mortality benefit, that’s a meaningful public health opportunity. But the under-performance of advanced providers is an equally important finding which suggests that training, clinical decision support, and quality feedback loops need to be part of any new drug or intervention. For anyone working in or around EMS policy, education, or governance in South Africa, this paper is worth reading in full. It’s likely to be referenced in upcoming scope-of-practice discussions at the HPCSA level.
