Exsanguinating polytrauma listed for damage control — abbreviation, ratios, clock, packs, closure

Examiner probes

1. The candidate says the lethal diamond predicts death better than the triad. Correct them — with the cohort numbers — then state your calcium practice.^[9][8][10]
2. Score his transfusion need and his early-death risk at the bedside: ABC variables with test characteristics, plus the admission predictor panel with values.^[12][13]
3. Ratios and cryoprecipitate: what does PROPPR actually prove, what does EAST recommend with what odds ratios, and what did the 49,301-patient cryoprecipitate analysis add?^[24][25][34]
4. TXA: dose, the three time windows with effects, the 90-minute and 2-hour refinements, and who is under-treated.^{[26][27][28][29][31]}
5. At stage 1, what do you deliberately NOT do — for liver, for destructive colon, for vessels — and when do packs come out?^{[48][47][40][41]}
6. Closure clock and honesty: SLEEP-TIME numbers, the matched harm of the unnecessary open abdomen, and the ITACTIC answer to viscoelastic believers.^[50][65][33]

Model responses

1. Diamond hypothesised, triad undefeated. Calcium touches every triad limb, motivating the diamond — but 2141 transfused severe-trauma patients (median ISS 27) gave diamond AUC 0.71 versus triad 0.72 (p equals 0.26): no incremental prediction.^[9][8] Practice: monitor ionised calcium (hypocalcaemia below 1.1), replace per protocol — half of prehospital patients are already low at 51 percent — but never protocolise empiric prehospital calcium before transfusion.^[10]

2. ABC 4; six-predictor panel. Penetrating mechanism, positive FAST, systolic 82, heart rate 135 — all four ABC variables; threshold 2 or more gives 75 percent sensitivity and 86 percent specificity for massive transfusion.^[12] Early-death predictors: INR above 1.2, base deficit above 3, head AIS 3 or more, temperature below 35, lactate above 6, haemoglobin below 7 — from 319 damage-control patients with 16.3 percent early death and lactate 5.81 versus 3.46 separating the dead from the survivors.^[13]

3. Haemostasis yes, mortality unproven; ratios recommended; cryo helps early. PROPPR 1:1:1 versus 1:1:2: mortality null at 24 hours and 30 days, exsanguination 9.2 versus 14.6 percent, haemostasis 86 versus 78 percent, no complication excess.^[24] EAST: run a protocol (OR 0.61), target high plasma (OR 0.60) and platelet (OR 0.44) ratios with empiric equal amounts, conditional early TXA.^[25] High cryoprecipitate ratios after the 2019 guideline change: adjusted OR 0.52 at 6 hours and 0.74 at 24 hours across 49,301 patients.^[34]

4. 1 g plus 1 g; ≤1 h RR 0.68, 1–3 h RR 0.79, >3 h RR 1.44 harm; refined to 90 minutes–2 h. CRASH-2 regimen and effects as above; PATCH analysis finds benefit only within 90 minutes (adjusted RR 0.64 versus 1.04 beyond); causal forest optimal rule is within 2 hours or GCS below 9.^{[26][27][28][29]} Women benefit equally (RR 0.69 versus 0.80) but receive TXA far less (OR 0.39) — check your own bay's equity.^[31]

5. Pack, staple, divert — never definitively repair. No destructive-colon anastomosis at stage 1 (25 percent leak at delay, leak kills; diversion equivalent); no major anatomic resection or atriocaval shunt (redundant — packing, suture, debridement and radiology replaced them); packs out at 36 to 72 hours with first look after 48 (21 versus 4 percent rebleed early).^{[48][47][40][41]}

6. Close early, open only with indication, test viscoelastics honestly. SLEEP-TIME: 92.9 percent closure, first takeback within 24 hours, minus 91.5 percent odds per extra laparotomy.^[50] Matched peritonitis harm of unnecessary open abdomen: 71.2 versus 41.4 percent complications, 22.5 versus 11.7 percent death.^[65] ITACTIC: viscoelastic-augmented versus conventional protocols identical (67 versus 64 percent transfusion-free at 24 hours; death 25 versus 28) — claim no superiority.^[33]