Written by Clay Smith
Prehospital administration of 2 units of thawed plasma in adult trauma patients at risk for hemorrhagic shock reduced mortality compared to standard care, NNT = 10.
Why does this matter?
Damage control resuscitation, early use of blood products for hemorrhagic shock in preference to crystalloid, has been shown to improve outcome in trauma patients, as in the PROPPR trial. Would early intervention with plasma in the prehospital setting reduce coagulopathy, hemorrhage, and prevent worsening shock?
PAMPer your patients
This was a multi-center RCT of prehospital air transport administration of 2 units thawed plasma in 501 adult patients at risk for hemorrhagic shock. It was called PAMPer (Prehospital Air Medical Plasma trial). Most had blunt trauma, though 18% of cases were penetrating. Specifically, to be included, patients needed to have at least one SBP < 90 or heart rate >108 at any point or severe hypotension, SBP <70, at any time prior to trauma center arrival.
Groups were randomized and well matched; roughly half received 2 units of thawed plasma en route to the hospital, and the other half received standard care. The standard care group received about 400cc more crystalloid and more PRBC transfusions. For the primary outcome of 30-day mortality, the plasma group was far better: 23.2%, plasma vs. 33.0%, standard care; difference, −9.8% (95% CI, −18.6 to −1.0), NNT = 10. This held for almost all pre-planned subgroups as well. Important secondary outcomes were also better, such as 24-hour mortality, in-hospital mortality, need for transfusion, and INR (1.2 plasma; 1.3 standard care). Only INR remained significant after adjusting the p-value for multiple comparisons. There were no safety issues with the administration of plasma, such as ARDS, infection, or multi-organ failure.
Prehospital Plasma during Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock. N Engl J Med. 2018 Jul 26;379(4):315-326. doi: 10.1056/NEJMoa1802345.
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Reviewed by Thomas Davis
I asked one of the authors his take home for PAMPer. He said,
Four years of hard work by many culminated in these findings that indeed FFP in the prehospital setting saves lives in those at risk for hemorrhagic shock. This study required coordination by many health care providers, especially our LifeFlight personnel. These dedicated heroes were focused on ensuring that every potential patient was enrolled. My personal opinion is that the closer we get to using whole blood, the more patients we will save. Minimizing crystalloid and utilizing colloid exclusively in this subgroup of injured patients makes sense and would be my strong suggestion as we continue to strive to reduce mortality in this challenging patient population.
Rick Miller, MD, FACS
Professor of Surgery
Chief, Division of Trauma, Surgical Critical Care and Emergency General Surgery
Carol Ann Gavin Directorship in Trauma and Surgical Critical Care
Vanderbilt University Medical Center