Bridging the gap: whole blood and plasma in prehospital hemorrhagic shock resuscitation

Abstract

Life-threatening hemorrhage remains a leading cause of preventable trauma-related mortality. Prehospital blood product administration has shown promise in improving outcomes; however, widespread implementation of whole blood programs faces significant logistical and operational challenges. Plasma represents a practical alternative that warrants thorough examination. Contemporary evidence, specifically the landmark PAMPer trial and secondary analysis of the COMBAT trial, demonstrates that prehospital plasma administration reduces 30-day mortality by 9.8% in trauma patients at risk of hemorrhagic shock, particularly when transport times exceed 20 minute. Plasma's efficacy stems from a reduction in trauma-induced coagulopathy and endothelial glycocalyx damage. While liquid plasma has a limited shelf life, dried plasma offers extended storage capability at room temperature for up to 2 years, presenting a logistically favorable option for emergency medical service (EMS) systems. Costs vary significantly between formulations, ranging from US$40 to US$100 for liquid plasma to US$700 to US$1500 for dried plasma. However, consideration must be given to the short shelf-life of liquid plasma. Prehospital plasma, particularly dried plasma, represents an important advancement in trauma management and represents a viable alternative to crystalloid-only resuscitation where whole blood may not be available or feasible. Implementation success depends on regional deployment strategies, blood bank partnerships, funding, training, and community engagement. Future research should focus on optimizing plasma utilization and improving patient outcomes through clinical and implementation-science approaches for EMS systems for which whole blood may not be an option.

Keywords: Emergency Medical Services; blood transfusion; hemorrhagic shock; plasma.

Figure 1. Dried plasma product. Images courtesy of Velico.