Trauma-induced coagulopathy and critical bleeding: the role of plasma and platelet transfusion

Abstract

Hemorrhage is responsible for 30 to 40% of all trauma-related mortality. Among adult trauma patients, 94% of hemorrhage-related deaths occur within 24 h and approximately 60% of these deaths within 3 h of hospital admission. Therefore, appropriate initial fluid resuscitation for bleeding is crucial to avoid preventable trauma-related death. In particular, the resuscitation strategy must be designed to complement prompt correction of anemia, coagulopathies, and thrombocytopenia. Conventional damage control resuscitation (DCR) of patients with severe trauma and massive hemorrhage is usually begun with rapid infusion of 1000 to 2000 mL of crystalloid fluids with subsequent transfusion of type O or uncross-matched red blood cells (RBCs) without plasma such as fresh frozen plasma (FFP) or platelets (PLTs). However, this DCR technique often leads to several adverse events such as abdominal compartment syndrome, acute respiratory distress syndrome, multiple organ failure, and dilutional coagulopathy. Simultaneous transfusion of FFP and PLTs along with the first units of RBCs while minimizing crystalloid infusion was recently recommended as a renewed DCR strategy. This aggressive RBC transfusion with FFP and PLTs is not only essential for the correction of coagulopathies and thrombocytopenia but also has the potential to ensure a good outcome in trauma patients. Additionally, it is important to maintain the resuscitation ratios of FFP/RBC and PLT/RBC. Most recently, DCR has been advocated for rapid hemorrhage control through early administration of a mixture of FFP, PLTs, and RBCs in a balanced ratio of 1:1:1.

Keywords: Acute coagulopathy of trauma shock; Acute traumatic coagulopathy; Damage control resuscitation; FFP; Fresh frozen plasma; Plasma; Platelet; Transfusion; Trauma; Trauma-induced coagulopathy.

Fig. 1

Conventional blood products and effects of administering them in ratios. a Composition of standard units of the following blood components: RBCs, FFP, and WBD PLTs. All PLT units in the Pragmatic Randomized Optimal Plasma and Platelet Ratios (PROPPR) study and 85% of PLTs used in the USA are in the form of apheresis units equal to six WBD units. The 55 billion PLTs in one WBD PLT unit occupy <0.5 mL. b Composition of the constituents in 1:1:1 and 1:1:2 mixtures of FFP, WBD PLTs, and RBC units. The top row is calculated directly from the contents, reflecting the extent to which anticoagulant and RBC additive solution dilute plasma and PLTs and RBCs are diluted by mixing with the other components. In the bottom row, the international normalized ratio and partial thromboplastin time values come from the experimental data of Kornblith et al. [23], whereas the circulating PLT counts given are 70% of the infused PLT counts to reflect the poor recovery of stored PLTs. Reproduced with permission [12]. RBCs red blood cells, FFP fresh frozen plasma, WBD whole blood-derived, PLTs platelets

Fig. 2

Mortality of massively transfused patients at 24 h stratified by platelet ratio. Adjusted for hypotension on admission (90 vs. 90 mmHg), GCS on admission (8 vs. 8), FFP/RBC ratio (%) at 24 h, and cryoprecipitate at 24 h. FFP fresh frozen plasma, GCS Glasgow Coma Scale, RBC red blood cell

Fig. 3

Kaplan–Meier survival plot for the first a 24 h and b 30 days after admission. a Kaplan–Meier survival plot for the first 24 h after admission for the four groups (high plasma (FFP _H) or platelet (Plt _H) to RBC ratio 1:2, low plasma (FFP _L) or platelet (Plt _L) to RBC ratio 1:2). b Kaplan–Meier survival plot for the first 30 days after admission for the four groups (high plasma (FFP _H) or platelet (Plt _H) to RBC ratio 1:2, low plasma (FFP _L) or platelet (Plt _L) to RBC ratio 1:2). FFP fresh frozen plasma, RBCs red blood cells

Fig. 4

Propensity-adjusted Kaplan–Meier survival plot for the first a 24 h and b 30 days after admission. a Propensity-adjusted Kaplan–Meier survival plot for the first 24 h after admission for the three platelet ratio groups: low (1:20), medium (1:2), and high (1:1). b Propensity-adjusted Kaplan–Meier survival plot for the first 30 days after admission for the three platelet ratio groups: low (1:20), medium (1:2), and high (1:1)