Page 29 - Journal of Special Operations Medicine - Fall 2014

the first 24 hours used in many of the above studies to casualties. 32,71,102–105 In a case series from the Mayo
3 or more units of RBCs in 1 hour. 92,93 In a study of 294 Clinic, prehospital plasma administration has been
severely injured patients performed at Memorial Her- shown to result in improved INRs by the time of arrival
mann Hospital in Houston, storing thawed plasma in at the emergency department. Additionally, plasma
106
the emergency department reduced the time delay to the has much better buffering capacity than crystalloids and
first administration of plasma from 89 minutes to 43 colloids and has been shown in a large animal model
107
minutes. This in turn was associated with a decrease in of multisystem trauma to reduce platelet dysfunction in
overall blood product use and a 60% odds reduction in comparison to resuscitation with NS. 108
30-day mortality after controlling for admission injury
severity and physiologic status. In a swine model of resuscitation from uncontrolled
94
hemorrhage with LR, Hextend, FFP, FFP and RBCs,
Another way to increase the availability of plasma for and FWB, resuscitation with FFP produced the lowest
use earlier in the resuscitation of patients in hemorrhagic postresuscitation blood loss of any of the fluids studied.
109
shock is to use liquid plasma (never-frozen) rather than Blood loss using plasma as a resuscitation fluid was ap-
FFP. Never-frozen liquid plasma has a favorable hemo- proximately half that seen in the Hextend animals. In
static profile compared with thawed plasma and can be another animal study that used a fixed-volume model of
stored at 1° to 6°C for up to 26 days. This product is otherwise lethal hemorrhage in swine, resuscitation with
95
now being used on the helicopter service at Memorial type-compatible FFP was observed to produce a survival
Hermann Hospital in Houston because of its substantial rate equal to resuscitation with whole blood and better
logistical advantage. 96 than that seen with either albumin or NS. 110

Prehospital resuscitation with balanced 1:1 RBC:plasma Mitra et al. showed that the administration of plasma in
ratios is now being used in the civilian sector in the high ratio to PRBCs (greater than or equal to 1:2) versus
United States. 52,97 It has also been used successfully on a low ratio (less than 1:2) within 4 hours of presentation
the United Kingdom’s Medical Emergency Response to the emergency department significantly improved
Team (MERT) evacuation platform in Afghanistan and survival (p = .03) in 159 trauma patients requiring a
may be a factor in the improved survival noted in the massive transfusion when a coagulopathy was present.
subset of severely injured casualties evacuated by the No benefit was found in 179 patients in whom coagu-
MERT compared with other evacuation platforms. lopathy was absent. 111
1,2
Plasma and RBCs should be available whenever logis-
tically feasible on TACEVAC platforms and may be While there is no Level 1 evidence that documents im-
98
available in some instances prior to TACEVAC, such as proved survival from prehospital resuscitation with
in mounted patrols and on ships at sea. Prehospital plasma alone, the available evidence indicates that this
99
resuscitation with RBCs and plasma in a civilian trauma practice may improve outcomes for casualties with se-
system has been shown to improve acid-base status and vere hemorrhage. 112
to reduce early mortality in the sickest patients com-
pared to resuscitation with crystalloids. DCR With DP
63
Although thawed plasma or liquid plasma is now be-
Damage Control Resuscitation With RBCs ing carried on some advanced capability TACEVAC
Brown and colleagues performed a retrospective study platforms, these options are typically not available dur-
of 1415 severely injured blunt trauma patients, 50 of ing TFC. Lyophilized (dried) plasma is a logistically
whom received RBCz before arrival at the trauma cen- attractive option for battlefield trauma care prior to
ter. Pretrauma center administration of RBCs (median TACEVAC. 32,52,98 DP offers the opportunity for both vol-
1.3 units) was associated with a significant reduction ume replacement and replacement of lost clotting factors.
in both 24-hour and 30-day mortality despite these pa- DP has been noted to have a good safety record 102,113 and
tients being more severely injured and having a longer has been approved for use by multiple coalition partner
transport time than the patients who did not receive pre- nations (United Kingdom, France, Germany, the Neth-
trauma center RBCs. Sixty-one casualties transported erlands) in the Afghanistan conflict. The French lyophi-
100
on board US Army DUSTOFF evacuation helicopters lized plasma product (FLyP) is now being used by some
were transfused with RBCs without any known adverse US Special Operations Forces under a treatment proto-
reactions or blood product wastage. 101 col, but the administrative aspects of the protocol are
complex and time-consuming. Additionally, the cost per
DCR With Thawed Plasma or Liquid Plasma unit for FLyP is currently much higher than Hextend or
Transfusion of plasma is the standard of care for the crystalloids. Another disadvantage of FLyP is the glass
114
treatment of the coagulopathy of trauma, which is seen bottle in which the product is supplied, which is break-
in a significant percentage of severely injured combat able and suboptimal for the medic’s combat load.

Fluid Resuscitation for Hemorrhagic Shock in TCCC 21