A 28-year-old motorcyclist arrives after high-speed collision with GCS 9, BP 90/60 mmHg, HR 130, RR 28. FAST exam is positive in Morrison's pouch. Despite 1 L crystalloid, BP remains 88/58. CT scan is deferred. Per current damage control resuscitation (DCR) principles, what is the most important immediate intervention?
- A Transfuse 4 units packed red cells before going to the operating room
- B Administer 2L crystalloid bolus then reassess hemodynamics
- C Activate massive transfusion protocol with 1:1:1 ratio (PRBC:FFP:platelets) and proceed to emergency laparotomy ✓
- D Permissive hypotension targeting MAP 50 mmHg with delayed intervention
Explanation
PROPPR trial demonstrated that a 1:1:1 ratio of PRBC:FFP:platelets (balanced resuscitation) reduces 24-hour mortality and increases hemostasis compared to delayed plasma strategies in hemorrhagic shock. With a positive FAST and hemodynamic instability despite initial resuscitation, immediate emergency laparotomy (damage control surgery) is required. Large-volume crystalloid alone worsens the 'lethal triad' (hypothermia, acidosis, coagulopathy). Permissive hypotension (MAP 50) is a DCR strategy only in penetrating trauma without TBI; here the GCS of 9 suggests TBI requiring MAP ≥80. Activating MTP with 1:1:1 while going to theater is the correct simultaneous action.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.