Our July, 2019 Quick Question was directed to trauma centers, and attracted 22 responses. The question was...
How does your institution manage trauma-induced coagulopathy?
- Crystalloid plasma expanders 3 (14%)
- pRBCs 2 (9%)
- 1:1:1 components 12 (54%)
- Whole blood 2 (9%)
- Tranexamic acid 3 (14%)
Thank you for your answers. Arising from military experience, a handful of facilities are returning to group O or group-specific whole blood, reasoning that whole blood provides all the components in the right proportion. It appears that the platelets in refrigerated whole blood provide activity in vivo even though they may not respond to aggregometry agonists.
Most trauma centers have moved from crystalloid plasma expanders and pRBCs, which raise the ristk of trauma-induced coagulopathy, to 1:1:1 ratio of pRBCs, plasma, and platelet concentrate. Trauma centers have built the 1:1:1 ratio into their massive transfusion protocols, reckoning that a pheresis platelet concentrate unit is the eequivalent of 6 whole blood-expressed "random" platelet concentrate. The update is based on a series of publications arising first from data collected during the Iraq and Afghanistan wars and extending to the present.
Tranexamic acid seems to be a successful substitute or adjunt to 1:1:1 therapy, reducing the need for the standard components.
- Holcomb JB, Pati S. Optimal trauma resuscitation with plasma as the primary resuscitative fluid: the surgeon’s perspective. Am Soc Hematol Educ Program. 2013; 2013:656–9.
- Robinson BR, Cotton BA, Pritts TA, et al. Application of the Berlin definition in PROMMT patients. J Trauma Acute Care Surg 2013; 75 (1 Suppl 1):S61–7.
- Practice guidelines for perioperative blood transfusion and adjuvant therapies: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood Transfusion and Adjuvant Therapies. Anesthesiology 2015;22:241–75.
- Novak DJ, Bai Y, Cooke RK, Marques MB, et al. Making thawed universal donor plasma available rapidly for massively bleeding trauma patients: experience from the Pragmatic, Randomized Optimal Platelets and Plasma Ratios (PROPPR) trial. Transfusion 2015; 55:1331–9.
- Pidcoke HE, McFaul SJ, Anand K, et al. Primary hemostatic capacity of whole blood: a comprehensive analysis of pathogen reduction and refrigeration effects over time. Transfusion 2013;53:137S–149S.
- Stubbs JB, Tran SA, Emery RL, et al. Cold platelets for trauma-associated bleeding: regulatory approval, accreditation approval, and practice implementation—just the “tip of the iceberg.” Transfusion 2017
- CRASH-2 trial collaborators (570). Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. The Lancet 2010; 376: 23-32