1. Pre-hospital Use of Plasma
Daniel Long, MD
6/30/2014

2. Trauma Facts Leading cause of death in persons <36 years old
More than all other causes combined for this group
Hemorrhage accounts for 40% of trauma deaths
Hess JR, Brohi K, Dutton RP, Hauser CJ, Holcomb JB, Kluger Y, Mackway-Jones K, Parr MJ, Rizoli SB, Yukioka T, Hoyt DB, Bouillon B. The coagulopathy of trauma: a review of mechanisms. J Trauma Oct;65(4):

3. Accidents Happen

4. Lessons from War - WWI Laparotomy for penetrating abdominal wounds
Blood transfusion
Volume loss is important in hypovolemic shock
Pruitt BA Jr. The symbiosis of combat casualty care and civilian trauma care: J Trauma Feb;64(2 Suppl):S4-8.

5. Lessons from War
Pruitt BA Jr. The symbiosis of combat casualty care and civilian trauma care: J Trauma Feb;64(2 Suppl):S4-8.

6. The Joint Theater Trauma System
Established in 2004
Data-driven performance improvement of trauma care within the military health system
7% of combat casualties require massive transfusion
Damage control resuscitation
Limit SBP at ~90 mmHg to prevent renewed bleeding
Use plasma as a primary resuscitation fluid in at least a 1:1 or 1:2 ratio with pRBCs
Holcomb JB, Jenkins D, Rhee P, Johannigman J, Mahoney P, Mehta S, Cox ED, Gehrke MJ, Beilman GJ, Schreiber M, Flaherty SF, Grathwohl KW, Spinella PC, Perkins JG, Beekley AC, McMullin NR, Park MS, Gonzalez EA, Wade CE, Dubick MA, Schwab CW, Moore FA, Champion HR, Hoyt DB, Hess JR. Damage control resuscitation: directly addressing the early coagulopathy of trauma. J Trauma Feb;62(2):

7. Lessons from War - Afghanistan
Morrison JJ, Oh J, DuBose JJ, O'Reilly DJ, Russell RJ, Blackbourne LH, Midwinter MJ, Rasmussen TE. En-route care capability from point of injury impacts mortality after severe wartime injury. Ann Surg Feb;257(2):330-4.

8. Trauma-induced Coagulopathy
Acute coagulopathy is present in 1 in 4 trauma patients at admission
Numerous factors likely play a role:
Hess JR, Brohi K, Dutton RP, Hauser CJ, Holcomb JB, Kluger Y, Mackway-Jones K, Parr MJ, Rizoli SB, Yukioka T, Hoyt DB, Bouillon B. The coagulopathy of trauma: a review of mechanisms. J Trauma Oct;65(4):

9. Trauma-induced Coagulopathy
Neal MD, Brown JB, Moore EE, Cuschieri J, Maier RV, Minei JP, Billiar TR, Peitzman AB, Cohen MJ, Sperry JL; The Inflammation and the Host Response to Injury Investigators. Prehospital Use of Nonsteroidal Anti-inflammatory Drugs (NSAIDs) Is Associated With a Reduced Incidence of Trauma-Induced Coagulopathy. Ann Surg Jan 13.

10. Thawed Plasma in the ED
Radwan ZA, Bai Y, Matijevic N, del Junco DJ, McCarthy JJ, Wade CE, Holcomb JB, Cotton BA. An emergency department thawed plasma protocol for severely injured patients. JAMA Surg Feb;148(2):170-5.

11. Plasma Usage
The 2011 National Blood Collection and Utilization Survey Report. Available at:

12. Pre-hospital Transfusion Criteria in TX
Two or more of the following:
Penetrating truncal mechanism
SBP <90 mmHg
HR >120 bpm
Positive FAST
Patient’s receive up to 2 units of plasma and 2 units of pRBCs, starting with plasma
Holcomb JB, Donathan DP, Cotton BA, Del Junco DJ, Brown G, Wenckstern TV, Podbielski JM, Camp EA, Hobbs R, Bai Y, Brito M, Hartwell E, Duke JR, Wade CE. Prehospital Transfusion of Plasma and Red Blood Cells in Trauma Patients. Prehosp Emerg Care Jun 16.

13. Pre-hospital transfusion in TX
Table 4.  Multivariate logistic regression for mortality within the
first 6 hours among those with critical ED disposition
(admitted directly to the ICU, IR, OR or morgue)
Odds ratio
95% CI
P-value LF
0.23
0.062–0.890
0.033
Arrival base deficit
0.87
0.799–0.955
0.003
Arrival rTEG ACT
1.02
1.001–1.043
0.035
Arrival SBP
0.93
0.904–0.966
<0.001
Blunt mechanism of injury
0.29
0.085–0.998
0.050
Prehospital crystalloid, mL
0.99
0.999–1.001
0.637
Holcomb JB, Donathan DP, Cotton BA, Del Junco DJ, Brown G, Wenckstern TV, Podbielski JM, Camp EA, Hobbs R, Bai Y, Brito M, Hartwell E, Duke JR, Wade CE. Prehospital Transfusion of Plasma and Red Blood Cells in Trauma Patients. Prehosp Emerg Care Jun 16.

14. Pre-hospital transfusion in MN
Kim BD, Zielinski MD, Jenkins DH, Schiller HJ, Berns KS, Zietlow SP. The effects of prehospital plasma on patients with injury: a prehospital plasma resuscitation. J Trauma Acute Care Surg Aug;73(2 Suppl 1):S49-53.

15. We Need a Prospective Trial!
PreHospital Air Medical Plasma Trial (PAMPer)
A four year phase III multicenter, prospective, randomized, open-label, interventional trial
Sponsor: University of Pittsburgh
Collaborators:
University of Texas
University of Louisville
Vanderbilt University
Case Western Reserve University
The University of Tennessee Knoxville

16. PAMPer Trial ( )
Goal: determine the effect of the pre-hospital infusion during air transport of 2 units of AB plasma in patients with hemorrhagic shock as compared to conventional care
Primary outcome: 30 day mortality
Secondary outcomes: 24 hr transfusion requirements, in-hospital mortality, multi-organ failure, acute lung injury, TRALI

17. Challenges of Pre-hospital Plasma
Plasma availability: group AB “universal” plasma comprises only ~4% of all donors
Potential solutions:
Group A plasma with low titers of anti-B
Pooled plasma
Hervig T, Doughty H, Ness P, Badloe JF, Berseus O, Glassberg E, Heier HE. Prehospital use of plasma: the blood bankers' perspective. Shock May;41 Suppl 1:39-43.

18. Challenges of Pre-hospital Plasma
Storage
FFP
Thawed plasma
Liquid plasma
Lyophilized plasma
Product wastage
Increased cost
Hervig T, Doughty H, Ness P, Badloe JF, Berseus O, Glassberg E, Heier HE. Prehospital use of plasma: the blood bankers' perspective. Shock May;41 Suppl 1:39-43.

19. Other Pre-hospital Players?
Tranexamic acid
Prevents fibrinolysis
DVT/PE risk?
PATCH study will address pre-hospital role
Prothrombin complex concentrate
Role in patients on vitamin K antagonists
More general role unlikely
Hervig T, Doughty H, Ness P, Badloe JF, Berseus O, Glassberg E, Heier HE. Prehospital use of plasma: the blood bankers' perspective. Shock May;41 Suppl 1:39-43.