Shock : molecular, cellular, and systemic pathobiological aspects and therapeutic approaches : the official journal the Shock Society, the European Shock Society, the Brazilian Shock Society, the International Federation of Shock Societies
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In past and ongoing military conflicts, the use of whole blood (WB) as a resuscitative product to treat trauma-induced shock and coagulopathy has been widely accepted as an alternative when availability of a balanced component-based transfusion strategy is restricted or lacking. In previous military conflicts, ABO group O blood from donors with low titers of anti-A/B blood group antibodies was favored. Now, several policies demand the exclusive use of ABO group-specific WB. ⋯ Emergency settings are often chaotic and resource limited, factors well known to increase the potential for human errors. Using ABO group-specific WB in emergencies may delay treatment because of needed ABO typing, increase the risk of clinical HTRs, and increase the severity of these reactions as well as increase the danger of underresuscitation due to lack of some ABO groups. When the clinical decision has been made to transfuse WB in patients with life-threatening hemorrhagic shock, we recommend the use of group O WB from donors with low anti-A/B titers when logistical constraints preclude the rapid availability of ABO group-specific WB and reliable group matching between donor and recipient is not feasible.
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This review is a synopsis of the decisions that shaped global policy on platelet (PLT) storage temperature and a focused appraisal of the literature on which those discussions were based. We hypothesize that choices were centered on optimization of preventive PLT transfusion strategies, possibly to the detriment of the therapeutic needs of acutely bleeding patients. Refrigerated PLTs are a better hemostatic product, and they are safer in that they are less prone to bacterial contamination. ⋯ Data from two randomized controlled trials bring into question the concept that stable autologous stem cell transplant patients with hypoproliferative thrombocytopenia should continue to receive prophylactic transfusions. At the same time, new findings regarding the efficacy of cold PLTs and their potential role in treating acute bleeding have revived the debate regarding optimal PLT storage temperature. In summary, a "one-size-fits-all" strategy for PLT storage may not be adequate, and a reexamination of whether cold-stored PLTs should be offered as a widely available therapeutic product may be indicated.
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Trauma-induced coagulopathy (TIC) occurs early after severe injury. TIC is associated with a substantial increase in bleeding rate, transfusion requirements, and a 4-fold higher mortality. Rapid surgical control of blood loss and early aggressive hemostatic therapy are essential steps in improving survival. ⋯ The effect of prehospital fibrinogen concentrate administration on outcome in major trauma patients is the subject of an ongoing prospective investigation. The use of prothrombin complex concentrate is potentially helpful in patients anticoagulated with vitamin K antagonists who experience substantial trauma or traumatic brain injury. Beyond emergency reversal of vitamin K antagonists, safety data on prothrombin complex concentrate use in trauma are lacking.
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Review
2013 RDCR Supplement: Role of Transfused Red Blood Cells for Shock and Coagulopathy within RDCR.
The philosophy of damage control resuscitation (DCR) and remote damage control resuscitation (RDCR) can be summarized by stating that the goal is to prevent death from hemorrhagic shock by "staying out of trouble instead of getting out of trouble." In other words, it is preferred to arrest the progression of shock, rather than also having to reverse this condition after significant tissue damage and organ injury cascades are established. Moreover, to prevent death from exsanguination, a balanced approach to the treatment of both shock and coagulopathy is required. This was military doctrine during World War II, but seemed to be forgotten during the last half of the 20th century. ⋯ Early reversal of shock is essential to prevent exacerbation of coagulopathy and progression of cell death cascades in patients with severe traumatic injuries. Red blood cell storage solutions have evolved to accommodate the needs of non-critically ill patients yet may not be optimal for patients in hemorrhagic shock. Continued focus on the recognition and treatment of shock is essential for continued improvement in outcomes for patients who require damage control resuscitation and RDCR.
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Randomized Controlled Trial Multicenter Study
Plasma First in the Field for Postinjury Hemorrhagic Shock.
Hemorrhage is the most preventable cause of death in civilian and military trauma, and despite tremendous advances in patient transport in the field, survival within the first hour has changed little over the past 40 years. The pathogenesis of trauma-induced coagulopathy is multifactorial, but most authorities believe there is an early depletion of clotting factors. ⋯ The rationale includes the possibility that plasma-first resuscitation may be advantageous beyond direct effects on clotting capacity. The study design is based on a ground ambulance system that allows rapid prehospital thawing of frozen plasma.