From Pages to Practice

By Lisa Caulley, MD, MPH, FRCSC

Published July 25, 2018


“We are transporting a 45-year-old man with a knife wound to the abdomen,” the voice of the paramedic crackled over the phone from the helicopter. “He is tachycardic at 108 beats per minute, systolic 70 mm Hg, respiratory rate 26 breaths per minute, temperature 98.6 degrees. We are 20 minutes out. What fluids do you want for him?”

Early initiation of damage-control resuscitation measures in traumatic injuries, including minimization of crystalloid and early blood component-based resuscitation, has the potential to reduce complications such as coagulopathy and irreversible shock. However, whether the benefits of prehospital plasma transfusion — including mitigating the inflammatory response after injury and reducing endothelial cell permeability following hemorrhagic shock — outweigh the potential risks is unclear.

In this week’s issue of NEJM, Sperry et al. investigated the role of adding prehospital plasma to standard resuscitation following traumatic injuries and hemorrhagic shock in a pragmatic, phase 3, multicenter, cluster-randomized trial. In the Prehospital Air Medical Plasma (PAMPer) trial, 501 severely injured patients at risk of hemorrhagic shock during air medical transport were randomized to receive either prehospital plasma resuscitation (thawed plasma) or standard-care resuscitation (prehospital crystalloid alone or crystalloid and red blood cells). Patients in the intervention group received two units of either group AB or group A low anti-B antibody titer thawed plasma administered by the transporting team in the prehospital setting.

The primary outcome, 30-day mortality, was significantly lower in patients in the prehospital plasma group than in patients in the standard-care group (23.2% vs. 33.0%). Adverse events were reported in 2.6% of patients in the plasma group and 1.5% of patients in the standard-care group. No differences between the two groups were observed in rates of multiple organ failure, acute lung injury, nosocomial infections, and allergic or transfusion reactions.

In an accompanying editorial, Jeremy Cannon noted the challenges associated with prehospital administration of plasma, including the need for cold storage and the short (5 days) shelf life. He concludes that the findings of the PAMPer trial are convincing and warrant consideration of a change in practice, but suggests the potential role for alternative approaches, including never-frozen liquid plasma or freeze-dried plasma, that obviate the need for temperature monitoring and offer a longer shelf life.

The results of the PAMPer trial support an improved life-saving strategy for patients who are hemorrhaging after major trauma. For the patient en route to your trauma center, these new data support a decision to initiate prehospital plasma resuscitation.

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Lisa was a 2017-2018 NEJM Editorial Fellow. An otolaryngologist-head and neck surgeon by training, she graduated from the University of Toronto Medical School and completed her residency training at the University of Ottawa. She has a Master's in Public Health from the Harvard T. H. Chan School of Public Health.