Damage control resuscitation (DCR) in massive hemorrhage employs a 1:1:1 ratio of packed red cells, fresh frozen plasma, and platelets. This strategy targets correction of which coagulopathy pattern seen in major trauma?

• A Dilutional coagulopathy from large-volume crystalloid resuscitation
• B Disseminated intravascular coagulation (DIC) from sepsis complicating trauma
• C Heparin rebound from massive transfusion of stored red cells
• D Acute traumatic coagulopathy (ATC), driven by tissue injury-mediated thrombomodulin activation, protein C activation, and hyperfibrinolysis ✓

Explanation

Acute traumatic coagulopathy (ATC) — now termed the acute coagulopathy of trauma-shock (ACoTS) — occurs in 25–35% of severely injured patients before any resuscitation. It is driven by massive tissue injury activating thrombomodulin on endothelial cells, which converts thrombin to activate protein C (aPC), downregulating factors Va and VIIIa and activating fibrinolysis (via PAI-1 inhibition). This endogenous anticoagulant state, combined with acidosis, hypothermia (the 'lethal triad'), is corrected by empiric 1:1:1 hemostatic resuscitation and tranexamic acid within 3 hours. Dilutional coagulopathy is avoided by restricting crystalloids.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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