Blunt polytrauma with pelvic fracture and hypotension — MTP, whole blood, calcium and TXA timing

Management walkthrough

Activate the MTP now — physiology plus mechanism plus FAST, scored formally. Systolic pressure 80 with tachycardia, unstable pelvis and positive FAST on 2 units meets every clinical trigger layer, and trigger-meeting patients given 1 to 3 units carry no excess harm signal — waiting for laboratories is the error, not activation.^[9] Score it while transfusing: TASH most validated, ABC without laboratories, shock index on vitals with fair performance.^[6] Resuscitate 1:1:1 plasma-platelets-red cells fast — exsanguination 9.2% vs 14.6% and haemostasis 86% vs 78% with complications equal — sequencing plasma early and delivering blood to the bay without delay.^[1][25][8]

Choose whole blood first at systolic pressure 80. He sits squarely in the verified benefit subgroup: no overall adjusted mortality difference across all comers, but SBP below 90 carries aOR 0.72 and below 70 aOR 0.64 for whole blood versus components.^[19] Give low-titre O whole blood first where the bank holds it; otherwise reconstituted 1:1:1 — and state the observational limit rather than promising trial proof.^[19][1] Either way, limit crystalloid and accept permissive hypotension to haemostasis in this blunt non-brain-injured bleeder: in-hospital death 6.3% vs 16.3% with fewer respiratory, organ-failure and DIC complications.^[24]

TXA 1 g with the first blood — 50 minutes is inside the best window. Dose 1 g loading over 10 minutes then 1 g over 8 hours: all-cause 14.5% vs 16.0%, bleeding death 4.9% vs 5.7%.^[2] At 50 minutes he is inside the within-1-hour band (RR 0.68) and the pooled within-2-hours optimal criterion — after 3 hours the same drug carries a harm signal (RR 1.44), so the loading dose runs now, not after theatre.^[3][4]

Replace calcium by level; ration fibrinogen by level with bleeding. Ionised 0.95 meets verified hypocalcaemia (1.0 or less): plasma-associated hypocalcaemia runs 53% vs 36% with survival tied to severe lows, while arrival means of 1.08 regardless show shock contributes — so give calcium under citrate load and recheck each round.^[14][16] Check fibrinogen with the first round and replace documented low-with-bleeding by protocol — never empirically for every activation, because 6-g-equivalent empirical cryoprecipitate changed 28-day death not at all (25.3% vs 26.1%) and five randomised trials total OR 1.03.^[10][11]

After haemostasis: pelvis, prophylaxis and disposition. Definitive pelvic control (binder to frame/external fixation per orthopaedics, angioembolisation on contrast blush), tibial washout and fixation once perfused, ICU with surgical and transfusion-medicine input — and VTE prophylaxis from the moment bleeding allows, because 13% of balanced-resuscitation patients develop VTE with pulmonary embolus predominant in the first 72 hours.^[21] Re-escalation triggers are written (pressure, lactate, drain output, calcium, fibrinogen, respiratory status), not assumed.