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Traumatic haemorrhage with documented hyperfibrinolysis — MRCEM SBA MCQ

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HardTraumaTraumatic haemorrhage with documented hyperfibrinolysisMRCEM SBA

A 46-year-old man arrives at a major trauma centre 4 hours 20 minutes after a high-speed collision. He has ongoing intra-abdominal haemorrhage and remains hypotensive despite blood-component resuscitation. The major haemorrhage protocol is active, and the trauma surgeon is preparing for immediate haemorrhage control. He has not received tranexamic acid. Rotational thromboelastometry shows marked clot breakdown: EXTEM maximal lysis is 32%, with lysis suppressed on APTEM. His fibrinogen is 2.5 g/L, platelet count is 192 × 10⁹/L and INR is 1.1. He takes no anticoagulant. Which is the most appropriate immediate haemostatic strategy?

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Correct answer: E — Continue haemorrhage control and give intravenous tranexamic acid now despite the elapsed time.

This patient has active, life-threatening traumatic bleeding, is more than 3 hours from injury, and has *demonstrated hyperfibrinolysis*. The pronounced EXTEM clot lysis, suppressed on APTEM, provides the evidence needed to apply the exception to NICE’s usual 3-hour limit for intravenous tranexamic acid. Give it now as an adjunct to blood-component resuscitation and immediate operative haemorrhage control; it does not replace either intervention. A is attractive because tranexamic acid is ordinarily avoided after 3 hours, but it overlooks the explicit hyperfibrinolysis exception. B would be reasonable if the initial tracing were uninterpretable or equivocal; here, repeat testing would delay treatment of a documented abnormality. C might be appropriate for emergency reversal of a vitamin K antagonist in an actively bleeding adult, but this patient takes no anticoagulant and has a normal INR. D addresses fibrinogen deficiency rather than the demonstrated excessive clot lysis. Fibrinogen replacement could be indicated if fibrinogen were low, but the stated concentration does not justify substituting it for tranexamic acid in this case.

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, recommendation 1.5.27 (17 February 2016) — https://www.nice.org.uk/guidance/ng39/chapter/recommendations FIBTEM Improves the Sensitivity of Hyperfibrinolysis Detection in Severe Trauma Patients: A Retrospective Study Using Thromboelastometry (2020) — https://pubmed.ncbi.nlm.nih.gov/32332776/