Following findings of the Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage (CRASH-2) trial, tranexamic acid (TxA) use post trauma is becoming widespread. However, issues of generalisability, applicability and predictability beyond the context of study sites remain unresolved. Internal and external validity of the CRASH-2 trial are currently lacking and therefore incorporation of TxA into routine trauma resuscitation guidelines appears premature. The Pre-hospital Antifibrinolytics for Traumatic Coagulopathy and Haemorrhage (PATCH)-Trauma study is a National Health and Medical Research Council-funded randomised controlled trial of early administration of TxA in severely injured patients likely to have acute traumatic coagulopathy. The study population chosen has high mortality and morbidity and is potentially most likely to benefit from TxA's known mechanisms of action. This and further trials involving appropriate sample populations are required before evidence based guidelines on TxA use during trauma resuscitation can be developed. © 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.