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Case

A 23-year-old male presents to the ED with multiple gunshot wounds to the chest and is hemodynamically unstable. Your clinical gestalt tells you he is going to need a massive transfusion.

Question

What is the effectiveness and safety of transfusing adult patients with severe trauma and major bleeding using plasma, platelets, and red blood cells (RBCs) in a 1:1:1 ratio versus a 1:1:2 ratio?

Background

Trauma is the leading cause of death in the United States among patients between the ages of 1 and 44. The U.S. Department of Defense developed damage-control resuscitation to try to prevent some of these deaths. It involves taking a balanced approach of providing blood products in a 1:1:1 ratio of plasma, platelets, and RBCs.

There have been no large, multicenter, randomized clinical trials with survival as a primary end point. The Prospective, Observational, Multicenter, Major Trauma Transfusion (PROMMTT) was a large observational trial that demonstrated that many clinicians were transfusing patients with a ratio of 1:1:1 or 1:1:2 and that early transfusion of plasma and platelets was associated with improved six-hour survival after admission.

Relevant Article

Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA. 2015;313(5):471-482.

• Population: Patients ≥15 years of age requiring at least 1 U of any blood component within the first hour of arrival or during prehospital transport and/or predicted by the Assessment of Blood Consumption (ABC) Score ≥2 or clinical gestalt to need massive transfusion.
• Intervention: 1:1:1 ratio
• Comparison: 1:1:2 ratio
• Outcome: All cause mortality at 24 hours and 30 days. Secondary outcomes: time to hemostasis, blood product volumes transfused, and complications.

Authors’ Conclusions

“Among patients with severe trauma and major bleeding, early administration of plasma, platelets, and red blood cells in a 1:1:1 ratio compared with a 1:1:2 ratio did not result in significant differences in mortality at 24 hours or at 30 days. However, more patients in the 1:1:1 group achieved hemostasis, and fewer experienced death due to exsanguination by 24 hours. Even though there was an increased use of plasma and platelets transfused in the 1:1:1 group, no other safety differences were identified between the two groups.”

Key Results

No statistically significant difference in mortality at 24 hours (12.7 percent versus 17.0 percent) or at 30 days (22.4 percent versus 26.1 percent) for 1:1:1 compared to 1:1:2 ratio.