Plasma as pre hospital resuscitation in trauma patients

J.L. Sperry, F.X. Guyette, J.B. Brown, M.H. Yazer et el published a trial of plasma vs standard fluid resuscitation in trauma patients who were at risk of hemorrhagic shock while being transported by air medical services.

BACKGROUND

In hospital treatment of trauma involves “damage control resuscitation” which aims to prevent coagulopathy by minimization of the use of crystalloid-based resuscitation in favor of early blood component–based resuscitation
that includes plasma and platelets in equal ratios with packed red cells.

Pre hospital resuscitation lacked evidence regarding these principles.

TRIAL

A pragmatic, multicenter, cluster-randomized, phase 3 trial involving injured patients who were at risk for hemorrhagic shock during air medical transport to a trauma center.

PATIENTS

18 to 90 yrs old trauma patients who had at least one episode of hypotension (systolic blood pressure <90 mm Hg) and tachycardia (defined in this trial as a heart rate >108 beats per minute) or if they had any severe hypotension (systolic blood pressure <70 mm Hg).

Following were excluded, if they had no IV access,  if they had had an isolated fall from standing, if they had a
documented cervical cord injury, if they were known to be a prisoner, if they were known to be pregnant, if they had a traumatic cardiac arrest that lasted longer than 5 minutes, if they had a penetrating brain injury, if their injury was due to isolated drowning or hanging, if they had burns over more than 20% of their total body surface area. Or patients relative objected to the study.

After exclusions, 271 were in standard group and 230 in treatment group.

INTERVENTION

Patients were randomized to receive 2 units of thawed plasma (either group AB or group A with a low anti-B antibody titer)standard-care resuscitation, which included infusion of a crystalloid solution as the primary resuscitative fluid, during the flight. If a patient remained hypotensive after the plasma infusion or had
obvious bleeding, transfusion of red cells then proceeded according to the local protocol.

OUTCOMES

Mortality at 30 days (Primary), secondary outcomes included mortality at 24 hours and in-hospital mortality; volumes of blood components and resuscitation fluid administered within 24 hours after enrollment; the incidence of multiorgan failure, acute lung injury–acute respiratory distress syndrome, transfusion-related acute lung
injury, and nosocomial infection; and indexes of coagulopathy on the basis of measurements of prothrombin-time ratio and results of thromboelastography.

RESULTS

Mortality at 30 days was significantly lower in the plasma group than in the standard-care group (23.2% vs. 33.0%;
difference, −9.8 percentage points; 95% confidence interval, −18.6 to −1.0%; P = 0.03).

PT or prothrombin time was lower in the plasma group 1.2 vs 1.3.

No significant differences between the two groups were noted with respect to multi-organ failure, acute lung injury–acute respiratory distress syndrome, nosocomial infections, or allergic or transfusion-related reactions.

IMPLICATIONS

Severe hemorrhage from traumatic injuries claim the lives of nearly 50,000 Americans every year.  Most deaths occur in first two hours. Temporary measures to control bleeding, minimizing factors that exacerbate hemorrhage, and shortening the time to definitive hemostasis may prevent some of these deaths.

Using plasma as resuscitation applies principles of damage control resuscitation to pre hospital care in trauma patients.

Plasma is not expensive, but requires cold storage and careful monitoring of temperature. Thawed plasma has half life of 5 days and can lead to waste of resources(but worth for the lives saved).  Alternative products such as never-frozen liquid plasma (shelf life 26 days) and Freeze dried plasma (2 yrs shelf life) needs to be tested in this situation.  Refrigerated whole blood is another alternative., which needs to be tested.

BOTTOMLINE

It may be coming soon to ambulance services in your neighborhood.

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