Bleeding laparotomy with consumption — SIC screen, JAAM-2 start, transfuse and time TXA

Model answer

(A) DIC with SIC-positive compensated disease — screen by SIC, start by JAAM-2 (3 marks). DIC is widespread microvascular thrombosis with consumptive coagulopathy causing thrombosis and hemorrhage.^[28] ISTH overt criteria from 2001 remain the global decompensated standard, with SIC introduced in 2019 to catch the compensated phase that leads to overt disease.^[3] His pattern (falling platelets and fibrinogen, raised D-dimer, long PT-INR with sepsis and organ dysfunction) is clinical-plus-laboratory DIC requiring repeated testing through the dynamic scenario.^[1] Screen and monitor by SIC (platelets, PT-INR and SOFA only), and let JAAM-2 (platelets, PT-INR and fibrinogen/FDP) guide treatment start — the only score showing effect modification for both benefit and harm.^[4][14][13]

(B) Bleeding-only products; no heparin while bleeding (4 marks). Products are reserved for bleeding, not numbers — with only three small RCTs under 100 patients showing no survival signal for FFP or platelets.^[1][2] He bleeds with consumption, so: consider platelets for bleeding or high-risk low platelets with no prophylactic transfusion when dry without high risk; give FFP for bleeding with prolonged PT/aPTT, never on labs alone, with no evidence that plasma fuels coagulation; and treat persistent severe hypofibrinogenaemia despite FFP with fibrinogen concentrate or cryoprecipitate.^[1] By numbers: maintain platelets above 50 while bleeding with 20 to 30 acceptable when dry.^[2] Heparin has no place while he bleeds: therapeutic heparin is for thrombotic phenotypes (thromboembolism, purpura fulminans with ischemia or infarction) with continuous UFH when bleeding threatens, and prophylactic heparin or LMWH only while critically ill and non-bleeding, with consensus LMWH until bleeding or platelets below 30.^[1][2]

(C) AT/rTM resolve DIC without proven survival gain; TXA only for early hyperfibrinolysis (3 marks). JSTH sepsis guidance recommends antithrombin and recombinant thrombomodulin (each GRADE 1B) with no clear heparin recommendation and combination therapy left as future research.^[7] The evidence split to state: antithrombin RCTs show no mortality difference with higher bleeding in both designs; AT and rhTM each raise DIC resolution rates without mortality or bleeding differences — so quote resolution separately from survival.^[9][11] Future trials must enrol severe, clearly DIC-defined patients without heparin masking, per the SCARLET critique.^[26] For TXA: blunt-trauma data study TXA within 3 hours with mortality odds tracking PT-INR, DIC score, APTT and falling fibrinogen — give early TXA for confirmed hyperfibrinolytic bleeding in this window, never for later shutdown-phase prothrombotic physiology.^[12]