Is there a role for aggressive use of fresh frozen plasma in massive transfusion of civilian trauma patients?



      Damage control resuscitation (DCR) with early plasma in combat casualties requiring massive transfusion (MT) decreases early deaths from bleeding.


      To ascertain the potential role of early plasma DCR in civilian MT, we queried a prospective traumatic shock database of 383 civilians.


      Ninety-three (24%) of the traumatic shock civilians received a MT, of which 26 (28%) died early, predominantly from bleeding within 6 hours. Comparatively, this early MT death cohort arrived in more severe shock and were coagulopathic (mean INR 2.4). In the critical period of MT (ie, the first 3 hours), these patients received 20 U of packed red blood cells (PRBCs) but only 4 U of fresh frozen plasma (FFP). They remained severely acidotic and their coagulopathy worsened as they exsanquinated.


      Civilians who arrived in traumatic shock, required a MT, and died early had worsening coagulopathy, which was not treated. DCR with FFP may have a role in civilian trauma.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The American Journal of Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Moore F.A.
        • Moore E.E.
        Initial management of patients with life-threatening trauma.
        in: Wilmore D.W. Cheung L.Y. Harken A.H. American College of Surgeons, ACS Surgery (formerly known as Scientific American Surgery). WebMD Corp, New York2006
        • Moore F.A.
        • Moore E.E.
        Post injury multiple organ failure.
        in: Moore E.E. Feliciano D.V. Mattox K.L. Trauma. 5th ed. McGraw Hill, New York2004: 1397-1423
        • Shoemaker W.C.
        • Appel P.L.
        • Kram H.B.
        • et al.
        Prospective trial of supranormal values of survivors as therapeutic goals in high-risk surgical patients.
        Chest. 1988; 94: 1176-1185
        • Moore F.A.
        • Haenel J.B.
        • Moore E.E.
        • et al.
        Incommensurate oxygen consumption in response to maximal oxygen availability predicts postinjury multiple organ failure.
        J Trauma. 1992; 33: 58-67
        • Yu M.
        • Levy M.M.
        • Smith P.
        • et al.
        Effects of maximizing oxygen delivery on morbidity and mortality in critically ill patients: a prospective randomized, controlled study.
        Crit Care Med. 1993; 21: 830-838
        • Balogh Z.
        • McKinley B.A.
        • Cox C.S.
        • et al.
        Abdominal compartment syndrome: the cause or effect multiple organ failure?.
        Shock. 2003; 20: 483-492
        • Meldrum D.R.
        • Moore F.A.
        • Moore E.E.
        • et al.
        Cardiopulmonary hazards of perihepatic packing for major liver injuries.
        Am J Surg. 1995; 170: 537-542
        • Balogh Z.
        • McKinley B.A.
        • Cocanour C.S.
        • et al.
        Supra-normal trauma resuscitation causes more cases of abdominal compartment syndrome.
        Arch Surg. 2003; 138: 637-643
        • Balogh Z.
        • McKinley B.A.
        • Holcomb J.B.
        • et al.
        Both primary and secondary abdominal compartment syndrome can be predicted early and are harbingers of Bad outcome.
        J Trauma. 2003; 54: 848-861
        • Moore F.A.
        • McKinley B.A.
        • Moore E.E.
        The next generation in shock resuscitation.
        Lancet. 2004; 363: 1988-1996
        • Cotton B.A.
        • Guy J.S.
        • Morris J.A.
        • et al.
        The cellular, metabolic, and systemic consequences of aggressive fluid resuscitation strategies.
        Shock. 2006; 26: 115-121
        • Brohi K.
        • Singh J.
        • Heron M.
        • et al.
        Acute traumatic coagulopathy.
        J Trauma. 2003; 54: 1127-1130
        • MacLeod J.B.
        • Lynn M.
        • McKenney M.G.
        • et al.
        Early coagulopathy predicts mortality in trauma.
        J Trauma. 2003; 55: 39-44
        • Hirshberg A.
        • Dugas M.
        • Banez E.I.
        • et al.
        Minimizing dilutional coagulopathy in exsanguinating hemorrhage: a computer simulation.
        J Trauma. 2003; 54: 454-463
        • Ho A.M.
        • Karmakar M.K.
        • Dion P.W.
        • et al.
        Enough coagulation factors during major trauma resuscitation?.
        Am J Surg. 2005; 190: 479-484
        • Holcomb J.B.
        • Jenkins D.
        • Rhee P.
        • et al.
        Damage control resuscitation: directly addressing the early coagulopathy of trauma.
        J Trauma. 2007; 62: 307-310
        • Gonzalez E.A.
        • Moore F.A.
        • Holcomb J.B.
        • et al.
        Fresh frozen plasma should be given earlier to patients requiring massive transfusion.
        J Trauma. 2007; 62: 112-119
        • Borgman M.A.
        • Spinella P.C.
        • Perkins J.G.
        • et al.
        The ratio of blood products transfused in patients receiving massive transfusions at a combat support hospital.
        J Truama. 2007; 63: 805-813
      1. Malone DL, Hess JR, Fingerhut A, et al. Transfusion practices around the globe and a suggestion for a common massive transfusion protocol. J Trauma [In press].

        • Gajic O.
        • Rana R.
        • Winters J.L.
        • et al.
        Transfusion-related acute lung injury in the critically ill.
        Am J Respir Crit Care Med. 2007; 176: 88-91
        • Cohn S.M.
        • Nathens A.B.
        • Moore F.A.
        • et al.
        Tissue oxygen saturation predicts the development of organ dysfunction during traumatic shock resuscitation.
        J Trauma. 2007; 62: 44-55
      2. Moore FA, Nelson T, McKinley BA, et al. Massive transfusion in trauma patients: tissue hemoglobin oxygen saturation predicts poor outcome. J Trauma [In press].

      3. Kashuk JL, Moore EE, Johnson JL, et al. Post-injury life threatening coagulopathy: is 1:1 fresh frozen plasma packed red blood cells the answer? J Trauma [In press].

        • Marshall J.C.
        • Cook D.J.
        • Christou N.V.
        • et al.
        Multiple organ dysfunction score: a reliable descriptor of a complex clinical outcome.
        Crit Care Med. 1995; 23: 1638-1652
        • Moore F.A.
        • Sauaia A.
        • Moore E.E.
        • et al.
        Postinjury multiple organ failure: a bimodal phenomenon.
        J Trauma. 1996; 40: 501-510
        • Smith W.R.
        • Moore E.E.
        • Osborn P.
        • et al.
        Retroperitoneal packing as a resuscitation technique for hemodynamically unstable patients with pelvic fractures: report of two representative cases and a description of technique.
        J Trauma. 2005; 59: 1510-1514
        • Alam H.B.
        • Chen Z.
        • Li Y.
        • et al.
        Profound hypothermia is superior to ultraprofound hypothermia in improving survival in a swine model of lethal injuries.
        Surgery. 2006; 140: 307-314
      4. Johnson JJ, Moore EE, Sauaia A, et al. Fresh frozen plasma is a independent risk factor for postinjury multiple organ failure. Arch Surg [In press].

      5. Cotton BA, Gunter OL, Isbell J, et al. Damage control hematology: the impact of a trauma exsanquination protocol on survival and blood product utilization. J Trauma [In press].

      6. Gunter OL, Au BK, Isbell JM, et al. Otimizing outcomes in damage control resuscitation: identifying blood product ratios associated with improved survival. J Trauma [In press].

        • Gonzalez E.A.
        • Jastrow K.
        • Holcomb J.B.
        • et al.
        Early achievement of a 1:1 ratio of FFP:PRBC reduces mortality in patients receiving massive transfusion.
        J Trauma. 2008; 64: 247
        • Sperry J.
        • Ochoa J.
        • Gunn S.
        • et al.
        FFP:PRBC transfusion ratio of 1:1 is associated with significantly lower risk of mortality following massive transfusion.
        J Trauma. 2008; 64: 247
        • Silverman T.
        • Aebersold P.
        • Landow L.
        • et al.
        Regulatory perspectives on clinical trials for trauma transfusion, and hemostasis.
        Transfusion. 2005; 45: 14S-21S
        • Wade C.E.
        • Holcomb J.B.
        Endpoints in clinical trials of fluid resuscitation of patients with traumatic injuries.
        Transfusion. 2007; 45: 4S-8S
        • McLaughlin D.F.
        • Niles S.E.
        • Salinas J.
        • et al.
        A predictive model for massive transfusion in combat casualty patients.
        J Trauma. 2008; 64: S57-S63
        • Schreiber M.A.
        • Perkins J.
        • Kiraly L.
        • et al.
        Early predictors of massive transfusion in combat casualities.
        J Am Coll Surg. 2007; 205: 541-545
        • Sloan E.P.
        • Koenigsberg M.
        • Gens D.
        • et al.
        A randomized, controlled efficacy trial of diaspirin cross linked hemoglobin (DCLHb) in the treatment of severe traumatic hemorrhagic shock.
        JAMA. 1999; 282: 1857-1864
        • Cheung A.M.
        • Tansey C.M.
        • George Tomlinson G.
        • et al.
        Two year outcomes, health care use and costs of survivors of acute respiratory distress syndrome.
        Am J Respir Crit Care Med. 2006; 174: 538-544
        • Ulvik A.
        • Kvale R.
        • Wentzel-Larsen T.
        • et al.
        Multiple organ failure after trauma affects long-term survival and functional status.
        Crit Care. 2007; 11: 1-8