Shock Syndromes II

In contrast, the benefits of prehospital plasma may not be as apparent in an urban setting with short

prehospital transport times. In a single-center study at Denver Health Medical Center, prehospital

plasma failed to improve mortality at 28 days (15% plasma vs. 10% control; p=0.37) and was

terminated early for futility after 144 enrollments.

Although logistical challenges are related to the storage and shelf life of plasma in a variety of

preparations, trauma centers may consider implementing prehospital plasma for patients at risk of

hemorrhagic shock, particularly in rural settings with longer transport times.

Massive transfusion: defined as a transfusion of 10 units or more of RBCs in 24 hours, 3 units of RBCs

over 1 hour, or any four blood components in 30 minutes

patients with suspected abdominal and thoracoabdominal injuries and detect hemorrhages in the

peritoneal, pleural, and pericardial cavities.

Clinical scores have been developed to assist in early identification of patients who would benefit

from activation of the MTP. The Assessment of Blood Consumption (ABC) Score was utilized in the

PROPPR trial for study enrollment. Two or more of the following criteria are associated with high

sensitivity and specificity for requiring an MTP: penetrating mechanism of injury, ED SBP 90 mm Hg

or less, ED heart rate 120 beats/minute or greater, or a positive FAST examination.

Current recommendations for the initial management of an expected massive hemorrhage include

PRBCs and plasma in a ratio of at least 2:1 as needed, or fibrinogen concentrate and PRBCs (European

Trauma Guidelines 2019; grade 1C).

Further resuscitation, including platelet transfusions, should be guided in a goal-directed fashion, using

either standard laboratory coagulation assays or viscoelastic tests (grade 1B). An example of goal-

directed resuscitation can be found in Table 4.

In a prospective study of 111 patients, TEG-guided resuscitation was superior to standard laboratory

coagulation-guided resuscitation with improved 6-hour mortality (7.1% vs. 21.8%; p=0.032) and total

mortality (19.6% vs. 36.4%; p=0.049) and required less plasma and platelets in the first 2 hours of

resuscitation. Notable limitations include single-center study design and TEG being available at point

of care. This finding is supported by growing evidence for viscoelastic testing in trauma care, but

adoption of TEG/ROTEM remains limited in some centers because of cost and resource constraints.

Conventional Coagulation Assay (CCA)

Thromboelastography (TEG)

INR ≥ 1.5: 2 units of FFP

Fibrinogen < 150 mg/dL: 10 pack of cryoprecipitate

Plt < 100,000/mm3: 1 unit of apheresis platelets

D-dimer > 0.5 mcg/mL: 1 g of tranexamic acid

Initial activated clotting time ≥ 140 s: 2 units of FFP, 10

pack of cryoprecipitate, 1 unit of apheresis platelets

Activated clotting time > 111–139 sa: 2 units of FFP

Alpha angle < 63: 10 pack of cryoprecipitate

MA < 55 mm: 1 unit of apheresis platelets

LY30b > 3%: 1 g of tranexamic acid

aEquivalent to R-time > 10

bLY30 is a reflection of fibrinolysis, similar to estimated percent lysis.

FFP = fresh frozen plasma; LY30 = percent decrease in amplitude after 30 minutes; MA = maximum amplitude; Plt = platelets.

Information from: Gonzalez E, Moore EE, Moore H, et al. Goal directed resuscitation of trauma induced coagulopathy: a pragmatic randomized clinical trial comparing