Implementing DCR in the bleeding trauma patient

Pillar 1 — Haemorrhage control. Tourniquet on the bleeding femur. Pelvic binder if pelvic instability. The FAST scan identifies the intra-abdominal bleeding — the destination for this unstable patient is the operating theatre for damage-control laparotomy, not the CT scanner.^[1] Pillar 2 — Blood-first 1-to-1-to-1. Activate the MTP immediately. Resuscitate with blood products (plasma, platelets, red cells approaching 1-to-1-to-1), not crystalloid. Monitor and replace the ionised calcium (the citrate chelates it). Give cryoprecipitate for the fibrinogen. Use the viscoelastic testing (ROTEM) if available.^[1] Pillar 3 — Permissive hypotension. Tolerate the systolic of 80 to 90 mmHg until the bleeding is controlled. Do NOT give crystalloid to chase a normal blood pressure — it disrupts the clots and accelerates the haemorrhage. (Unless there is a TBI — then maintain the systolic above 110.)^[1] Pillar 4 — TXA within 3 hours. Give 1 gram IV bolus then 1 gram over 8 hours, as early as possible — ideally at the scene or on arrival. Beyond 3 hours the benefit is lost.^[1] Prevent the lethal triad. Warm the patient (blankets, warmed fluids, ambient temperature). Give blood products not crystalloid (avoids the dilutional coagulopathy). Correct the acidosis through the restoration of the perfusion. The MTP, the TXA and the warming run simultaneously with the primary survey and the theatre call.^[1]