Indications for early fresh frozen plasma, cryoprecipitate, and platelet transfusion in trauma. Discussion

Background: Massive blood transfusion can be lifesaving in the treatment of severe trauma. Guidelines for the use of non-RBC blood components in the early phase of trauma resuscitation are largely based on extensions of expert recommendations for general surgery. Methods: The logic and evidence for the use of plasma, platelets, and cryoprecipitate early in the course of massive transfusion for trauma were reviewed. Large series of consecutive patients were sought. Findings: Resuscitation of the most severely iniured and massively hemorrhaeine patients usually starts with crystalloid fluids and progresses to uncross-matched RBC. Low blood volume, insensible losses, consumption, and resuscitation with plasma poor RBC concentrates rapidly lead to plasma coagulation factor concentrations of less than 40%. This typically occurs before 10 U of RBC have been transfused. Early initiation of plasma therapy is often delayed by its lack of immediate availability in the trauma center. Platelets usually fall to concentrations of 50-100× 109/L after 10-20 units of RBC have been given, but platelet concentrations in individual patients are quite variable and can decrease more quickly. Ideal platelet concentrations in trauma patients are not known, but are generally held to be greater than 50 × 10 9 /L. Cryoprecipitate can rapidly increase the concentrations of fibrinogen and von Willebrand's factor, but the advantages of higher than normal concentrations are speculative. Conclusions: Early use of plasma and platelets at the upper end of recommended doses appears to reduce the incidence of coagulopathy in massively transfused individuals.