Massive transfusion in the bleeding surgical patient — trigger, ratio, TXA, fibrinogen and calcium

Examiner probes

1. He is hypotensive with a positive FAST and 2 units running. Activate or wait — and with what score, ratio, sequence and speed?^{[6][1][25][8]}
2. Injury was 75 minutes ago. TXA — dose, timing numbers, and what happens if you miss the window?^[2][3][4]
3. Fibrinogen for everyone or for the low — and calcium with every round? Defend both with the trials.^{[10][11][14][16]}
4. Whole blood or components for this pressure — and what do you watch for after haemostasis?^{[19][9][21][24]}

Model responses

1. Activate now — 1:1:1 fast with plasma early, scored formally. Hypotension with active bleeding and blood running meets clinical triggers, and 1 to 3 units in trigger-meeting patients carry no excess harm signal — activation is the safe error direction.^[9] Formalise it: TASH most validated, ABC without laboratories, shock index on vitals with fair performance — 45 articles, 11 validated scores.^[6] Give 1:1:1 plasma-platelets-red cells during active resuscitation (PROPPR: 338 vs 342, exsanguination 9.2% vs 14.6%, haemostasis 86% vs 78%, 23 complications equal), sequence plasma early (red-cell-first carries worse adjusted mortality), and deliver fast — shorter time to blood means better outcomes, within the 1:1:1 to 1:1:2 protocol range.^[1][25][8]

2. TXA 1 g now — inside every window that matters. Give 1 g loading over 10 minutes then 1 g over 8 hours: CRASH-2 all-cause 14.5% vs 16.0% (RR 0.91), bleeding death 4.9% vs 5.7% (RR 0.85).^[2] At 75 minutes he sits in the best gradient band — within 1 hour RR 0.68, 1 to 3 hours RR 0.79, after 3 hours harm RR 1.44 — and inside the pooled optimal criterion of within 2 hours of injury.^[3][4] Missing the window converts benefit to harm: after 3 hours TXA is not merely useless but suspect, so the dose travels with the first blood, never after the operation.

3. Fibrinogen targeted, calcium routine. No empirical cryoprecipitate for every activation: 3 pools (6-g equivalent) within 90 minutes gave 28-day death 25.3% vs 26.1% with equal thrombosis, and five randomised trials total 24% vs 25% (OR 1.03) — replace documented hypofibrinogenaemia with bleeding only.^[10][11] Calcium is the opposite: measure ionised levels every round, because plasma raised hypocalcaemia (1.0 or less) to 53% vs 36% with survival tied to severe lows — while arrival means of 1.08 regardless prove shock contributes too, so replace by level under citrate load.^[14][16]

4. Whole blood first at this pressure — then restraint plus VTE vigilance. At systolic pressure 84 he is inside the verified benefit subgroup (below-90 aOR 0.72, below-70 aOR 0.64) against no overall adjusted difference — offer low-titre O whole blood first where available, 1:1:1 otherwise, naming the observational limit.^[19] After haemostasis: stop escalating (small volumes carry no excess signal, large ones do worse), run limited-volume hypotensive resuscitation only where brain injury is absent (in-hospital 6.3% vs 16.3%), and start VTE prophylaxis at haemostasis — 13% VTE with early PE dominance in the first 72 hours.^[9][24][21]