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Traumatic haemorrhagic shock with hyperfibrinolysis — MRCEM SBA MCQ

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HardTraumaTraumatic haemorrhagic shock with hyperfibrinolysisMRCEM SBA

A 36-year-old man arrives at a major trauma centre 3 hours 40 minutes after a motorcycle collision. His airway and ventilation are adequate. He is pale, with a heart rate of 132/min and blood pressure of 78/46 mmHg despite blood-component resuscitation. FAST shows free intraperitoneal fluid, and the trauma surgeon is preparing for immediate laparotomy. No tranexamic acid has been given. Rapid viscoelastic testing reports marked hyperfibrinolysis. What is the most appropriate tranexamic acid plan?

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Correct answer: E — Give tranexamic acid while proceeding to laparotomy.

This patient has ongoing major traumatic haemorrhage and has not responded to blood-component resuscitation. He needs immediate operative haemorrhage control; tranexamic acid is an adjunct, not a reason to delay laparotomy. NICE advises against intravenous tranexamic acid more than 3 hours after major trauma **unless there is evidence of hyperfibrinolysis**. His viscoelastic result supplies that exception, so giving it now while proceeding to surgery is the best answer. ([nice.org.uk](https://www.nice.org.uk/guidance/ng39/chapter/Recommendations)) A applies the usual 3-hour restriction but overlooks its explicit exception. B is tempting because laboratory results guide subsequent blood-component treatment, but standard coagulation tests need not precede treatment when hyperfibrinolysis is already demonstrated. C reverses the sequence: definitive haemorrhage control is urgent, yet tranexamic acid need not wait for it. D might be reasonable if the initial result were unreliable or inconsistent with the clinical picture; neither concern is given here. Continuing blood-component resuscitation and moving promptly to haemorrhage control remain essential regardless of the tranexamic acid decision. ([nice.org.uk](https://www.nice.org.uk/guidance/ng39/chapter/Recommendations))

Reference: NICE NG39: Major trauma: assessment and initial management, recommendations 1.5.4–1.5.5 (17 February 2016) — https://www.nice.org.uk/guidance/ng39/chapter/Recommendations NICE NG39: Major trauma: assessment and initial management, recommendations 1.5.27 and 1.5.29 (17 February 2016) — https://www.nice.org.uk/guidance/ng39/chapter/Recommendations