Bleeding after damage-control laparotomy — activate, ratio, TXA, fibrinogen and calcium

Model answer

(A) Activate now on physiology — balanced 1:1:1 fast with plasma early (4 marks). Hypotension with ongoing drain output after 3 units meets clinical MTP triggers — and among trigger-meeting patients, even 1 to 3 units carry no excess harm signal, so activation cannot be called over-triage in retrospect.^[9] Score it formally: TASH is the most well validated trigger score, ABC balances accuracy with ease where laboratories lag, and shock index runs on vitals alone with fair performance — use all three layers, and transfuse while tallying.^[6] Resuscitate 1:1:1 plasma-platelets-red cells during active bleeding per PROPPR (338 vs 342 patients; exsanguination 9.2% vs 14.6%, haemostasis 86% vs 78%, with 23 complications equal) — within the accepted 1:1:1 to 1:1:2 protocol range — sequencing plasma early (red-cell-first carries worse adjusted 6-hour, 24-hour and in-hospital mortality) and delivering fast, because shorter time to blood means better outcomes.^[1][25][8]

(B) TXA now — 1 g load inside the 2-hour window; fibrinogen only if the level with bleeding justifies it (3 marks). Injury was 2 hours ago, so give TXA 1 g loading over 10 minutes then 1 g over 8 hours immediately: CRASH-2 dosing cut all-cause death (14.5% vs 16.0%) and bleeding death (4.9% vs 5.7%).^[2] Timing is the whole decision — within 1 hour RR 0.68, 1 to 3 hours RR 0.79, after 3 hours harm RR 1.44 — and the pooled optimal criterion is treatment within 2 hours of injury, which he still meets.^[3][4] For low fibrinogen with active bleeding, replace by local protocol for documented hypofibrinogenaemia — but do not protocolise empirical cryoprecipitate for every activation (no verified threshold is quoted here; use your protocol's number): CRYOSTAT-2 (3 pools, 6-g equivalent, within 90 minutes) gave 28-day death 25.3% vs 26.1% with equal thrombosis, and the 5-trial meta-analysis found 24% vs 25% (OR 1.03).^[10][11]

(C) Calcium 0.94 is low — replace under load and recheck; whole blood suits his pressure; watch for early PE (3 marks). Ionised 0.94 meets the verified hypocalcaemia threshold (1.0 or less): plasma transfusion raised hypocalcaemia to 53% vs 36% with severe lows tied to decreased survival — yet arrival means sit at 1.08 regardless of transfusion, so his level reflects shock plus citrate and earns replacement with rechecks each round, consistent with the whole-blood dosing signal (1 g or more calcium chloride per 2 units, OR 0.164 for 24-hour death).^[14][16][15] At systolic pressure 82 he sits in the whole-blood-benefit subgroup (below-90 aOR 0.72) — offer low-titre O whole blood first where available, otherwise reconstituted 1:1:1, stating the observational limit aloud.^[19] From haemostasis, start mechanical VTE prophylaxis and convert to pharmacologic cover promptly: 13% of PROPPR patients developed VTE with pulmonary embolus predominant in the first 72 hours.^[21]