ATLS primary survey — tranexamic acid and the exsanguinating patient

(A) Haemorrhage control sequence (3 marks). Catastrophic external haemorrhage precedes airway — the <C>ABC reordering — so I control the thigh bleeding first while the team runs the rest of the survey in parallel. Direct pressure, then a tourniquet for life-threatening extremity bleeding that pressure cannot control. Tourniquets are lifesaving but not a default: in a civilian prehospital series of 211 placements, 63.2% had no other intervention attempted first, nearly a third of limbs arrived with palpable distal pulses, and fewer than half had arterial bleeding on release.^[2] The Russo-Ukrainian war shows the harm of the reflex: unnecessary loss of extremities and life-threatening prolonged tourniquet application syndrome from non-indicated tourniquets combined with long evacuation.^[1] So: indicated, applied tight, timed, and reassessed.

(B) Tranexamic acid (4 marks). CRASH-2 randomised 20,211 adults with, or at risk of, significant bleeding, within 8 hours of injury, to TXA 1 g over 10 minutes then 1 g over 8 hours or placebo. All-cause mortality fell from 16.0% to 14.5% (RR 0.91, 95% CI 0.85–0.97) and death due to bleeding from 5.7% to 4.9% (RR 0.85).^[3] The timing analysis is the quotable part: within 1 hour RR 0.68 for death from bleeding; between 1 and 3 hours RR 0.79; after 3 hours RR 1.44 — treatment seemed to increase death from bleeding (4.4% vs 3.1%).^[4] He is 40 minutes post-injury: give it now, and I state the window explicitly.

(C) Fluid and blood (3 marks). Blood, not crystalloid. PROPPR randomised 680 patients predicted to need massive transfusion to 1:1:1 versus 1:1:2 plasma:platelets:red cells: overall mortality did not differ significantly, but exsanguination in the first 24 hours fell with 1:1:1 (9.2% vs 14.6%) and more patients achieved haemostasis (86% vs 78%).^[5] Prehospital transfusion has military cohort support: in the Afghan MEDEVAC cohort, prehospital blood recipients had 24-hour mortality 5% versus 19% and 30-day mortality 11% versus 23% in non-recipients.^[6] My endpoints are control of the bleeding source plus goal-directed resuscitation, not a normal blood pressure.