Blunt polytrauma with hypotension and hypocalcaemia — activate, ratio, clock, calcium and whole-blood choice

Model answer

(A) Resuscitation-first doctrine, activated on physiology, run at equal ratios (4 marks). Damage control resuscitation focuses on initial hypotensive resuscitation and early blood products to prevent the lethal triad of acidosis, coagulopathy and hypothermia — while DCS is abbreviated laparotomy prioritising physiology over anatomy — and DCR may let borderline patients who previously needed DCS undergo early definitive surgery instead.^[47] He meets activation on physiology alone: penetrating-or-blunt mechanism with positive FAST, systolic at or below 90 and heart rate at or above 120 score the four ABC variables, with lactate 6.4 and temperature 34.9 completing the bleeding picture — never wait for laboratory coagulation, which arrives normal while lactate already screams shock.^[32] Run equal amounts of red cells, plasma and platelets in the early empiric phase per EAST (protocol OR 0.61, high plasma OR 0.60, high platelets OR 0.44), accepting PROPPR's honesty — no 24-hour or 30-day mortality difference (12.7 versus 17.0%, 22.4 versus 26.1%), fewer exsanguinations (9.2 versus 14.6%), more haemostasis (86 versus 78%), complications equal across all 23 prespecified.^[8][5] Formalise the score but distrust its negative: applied to PROPPR bleeders an ABC of 2 managed only 66.8% sensitivity and 37.0% specificity, and a third of trial patients entered by gestalt below threshold — so a low score never vetoes blood in a bleeding patient.^[35]

(B) TXA now by the clock, calcium by the level (3 marks). Give 1 g over 10 minutes then 1 g over 8 hours immediately: at 55 minutes he sits in the best band — within-1-hour bleeding-death RR 0.68, 1-to-3-hour RR 0.79, beyond-3-hour RR 1.44 — with PATCH-TXA refining the window to 90 minutes (inside aRR 0.64, beyond aRR 1.04).^[16][17][18] His ionised calcium of 0.98 meets verified hypocalcaemia (1.0 or less): prehospital plasma pushed lows from 36% to 53% with severe lows predicting worse survival — so measure ionised calcium with every round and replace under citrate load.^[21] Then state the counterweight that separates pass from distinction: in 346 protocol activations 83.2% were hypocalcaemic yet neither first calcium nor citrate-corrected dose touched mortality — so check-and-replace is defended, fixed-dose mortality claims are not, and no milligram dose is stated on this evidence.^[22]

(C) Components by default, whole blood by logistics, fibrinogen and VHA with restraint (3 marks). Two 2026 prehospital randomised trials were neutral — TOWAR 30-day death 25.9% whole blood versus 20.5% components, English composite 48.7% versus 47.7% — so choose whole blood where it simplifies the chain (prehospital, single-bag logistics, proven LTO-WB safety with identical 73 versus 74% survival) and balanced components where the bank runs equal ratios well.^[12] Give no empiric cryoprecipitate: 3 pools early changed 28-day death not at all (25.3 versus 26.1%) — replace documented hypofibrinogenaemia with bleeding only.^[28] Use viscoelastic assays as early-warning adjuncts, quoting ITACTIC neutrality (alive free of massive transfusion 67 versus 64%, mortality 25 versus 28%) — never a superiority claim, never a cutoff this evidence lacks.^[25] With concomitant severe brain injury everything shifts: no permissive hypotension (the 84.3%-except-TBI professional consensus), TXA by the coma-scale rule with benefit possibly persisting past 2 hours when GCS sits below 9, and pressure targets set for the brain, not the clot.^[1]