We had Dr. John Holcomb on the how about nine year ago when his PROPPR study came out. There has been so many RCTs published since then, so we brought Dr. Holcomb back for an update.
Dr. Holcomb is a Trauma Surgeon at University of Alabama at Birmingham. He spent decades in the military as a surgeon before continuing his career as one of the preeminent trauma surgeons in the US civilian world.
DCR Review from Holcomb
Lammers, Danny T., and John B. Holcomb. “Damage Control Resuscitation in Adult Trauma Patients: What You Need to Know.” Journal of Trauma and Acute Care Surgery 95, no. 4 (October 2023): 464–71. https://doi.org/10.1097/TA.0000000000004103.
Low Titer O Whole Blood (LTOWB) compared to Component Therapy
- Feinberg, Griffin J., Anastasia C. Tillman, Marcelo L. Paiva, Brent Emigh, Stephanie N. Lueckel, Allyson M. Hynes, and Tareq Kheirbek. “Maintaining a Whole Blood-Centered Transfusion Improves Survival in Hemorrhagic Resuscitation.” Journal of Trauma and Acute Care Surgery 96, no. 5 (May 2024): 749–56. https://doi.org/10.1097/TA.0000000000004222.
- Shea, Susan M., Emily P. Mihalko, Liling Lu, Kimberly A. Thomas, Douglas Schuerer, Joshua B. Brown, Grant V. Bochicchio, and Philip C. Spinella. “Doing More with Less: Low-Titer Group O Whole Blood Resulted in Less Total Transfusions and an Independent Association with Survival in Adults with Severe Traumatic Hemorrhage.” Journal of Thrombosis and Haemostasis: JTH 22, no. 1 (January 2024): 140–51. https://doi.org/10.1016/j.jtha.2023.09.025.
- Torres, Crisanto M., Alistair Kent, Dane Scantling, Bellal Joseph, Elliott R. Haut, and Joseph V. Sakran. “Association of Whole Blood With Survival Among Patients Presenting With Severe Hemorrhage in US and Canadian Adult Civilian Trauma Centers.” JAMA Surgery 158, no. 5 (May 1, 2023): 532. https://doi.org/10.1001/jamasurg.2022.6978.
- Horst, Robert A. van der, Tim W. H. Rijnhout, Femke Noorman, Boudewijn L. S. Borger van der Burg, Oscar J. F. van Waes, Michael H. J. Verhofstad, and Rigo Hoencamp. “Whole Blood Transfusion in the Treatment of Acute Hemorrhage, a Systematic Review and Meta-Analysis.” The Journal of Trauma and Acute Care Surgery 95, no. 2 (August 1, 2023): 256–66. https://doi.org/10.1097/TA.0000000000004000.
- Meizoso, Jonathan P., Bryan A. Cotton, Ryan A. Lawless, Lisa M. Kodadek, Jennifer M. Lynde, Nicole Russell, John Gaspich, et al. “Whole Blood Resuscitation for Injured Patients Requiring Transfusion: A Systematic Review, Meta-Analysis, and Practice Management Guideline from the Eastern Association for the Surgery of Trauma.” The Journal of Trauma and Acute Care Surgery 97, no. 3 (September 1, 2024): 460–70. https://doi.org/10.1097/TA.0000000000004327.
- Who gets whole blood
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How much before you switch to component therapy?
Blood as a Triage Tool
Triggers
- Does 1 unit of whole blood satisfy the CAT?
- What is your MAP goal?
Walking Blood Banks for Rural Trauma
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Holcomb, John B., Philip C. Spinella, Torunn Oveland Apelseth, Frank K. Butler, Jeremy W. Cannon, Andrew P. Cap, Jason B. Corley, et al. “Civilian Walking Blood Bank Emergency Preparedness Plan.” Transfusion 61, no. S1 (July 2021). https://doi.org/10.1111/trf.16458.
Component Therapy Ratios
PROPPR tells us 1:1:1 is the win
- 1:1 vs. 1:2?
Thromboelastography
Calcium
Prothrombin Complex Concentrate
ProCoag
Gave a lot of PCC in addition to 1:1-1:2
ancillary study shows thrombin burst for period after admin, but procoag gave FFP as well
- Bouzat, Pierre, Jonathan Charbit, Paer-Selim Abback, Delphine Huet-Garrigue, Nathalie Delhaye, Marc Leone, Guillaume Marcotte, et al. “Efficacy and Safety of Early Administration of 4-Factor Prothrombin Complex Concentrate in Patients With Trauma at Risk of Massive Transfusion: The PROCOAG Randomized Clinical Trial.” JAMA 329, no. 16 (April 25, 2023): 1367. https://doi.org/10.1001/jama.2023.4080.
- What about rural environments?
Tranexamic Acid (TXA)
PATCH Trial
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PATCH-Trauma Investigators and the ANZICS Clinical Trials Group, Russell L. Gruen, Biswadev Mitra, Stephen A. Bernard, Colin J. McArthur, Brian Burns, Dashiell C. Gantner, et al. “Prehospital Tranexamic Acid for Severe Trauma.” The New England Journal of Medicine 389, no. 2 (July 13, 2023): 127–36. https://doi.org/10.1056/NEJMoa2215457.
2020 TCCC Guideline Updates
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- Shifted to a 2g IV bolus instead of a 1 g bolus in military settings, in addition to including TBI as an indication for TXA use
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- Drew, B., Auten, J., Cap, A., Deaton, T., Donham, B., Dorlac, W., DuBose, J., Fisher, A. D., Ginn, A. J., Hancock, J., Holcomb, J. B., Knight, J., Knight, R., Koerner, A., Littlejohn, L., Martin, M. J., Morey, J., Morrison, J., Schreiber, M., … Butler, F. (2020). The Use of Tranexamic Acid in tactical combat casualty care. Journal of Special Operations Medicine, 20(3), 36–43. https://doi.org/10.0000/0000
- Yelle, K., Woo, M.Y., Saidenberg, E., Lampron, J. (2020). The Use of Tranexamic Acid in Trauma Patients- a Retrospective Review, unpublished manuscript, The University of Ottawa.
- Rowell, S. E., Meier, E. N., McKnight, B., Kannas, D., May, S., Sheehan, K., Bulger, E. M., Idris, A. H., Christenson, J., Morrison, L. J., Frascone, R. J., Bosarge, P. L., Colella, M. R., Johannigman, J., Cotton, B. A., Callum, J., McMullan, J., Dries, D. J., Tibbs, B., … Schreiber, M. A. (2020). Effect of Out-of-Hospital Tranexamic Acid vs Placebo on 6-Month Functional Neurologic Outcomes in Patients With Moderate or Severe Traumatic Brain Injury. JAMA, 324(10), 961–974. https://doi.org/10.1001/jama.2020.8958
- Guyette, F. X., Brown, J. B., Zenati, M. S., Early-Young, B. J., Adams, P. W., Eastridge, B. J., Nirula, R., Vercruysse, G. A., O’Keeffe, T., Joseph, B., Alarcon, L. H., Callaway, C. W., Zuckerbraun, B. S., Neal, M. D., Forsythe, R. M., Rosengart, M. R., Billiar, T. R., Yealy, D. M., Peitzman, A. B., & Sperry, J. L. (2020). Tranexamic Acid During Prehospital Transport in Patients at Risk for Hemorrhage After Injury. JAMA Surgery, E1–E10. https://doi.org/10.1001/jamasurg.2020.4350
Cryostat2
- Davenport, Ross, Nicola Curry, Erin E. Fox, Helen Thomas, Joanne Lucas, Amy Evans, Shaminie Shanmugaranjan, et al. “Early and Empirical High-Dose Cryoprecipitate for Hemorrhage After Traumatic Injury: The CRYOSTAT-2 Randomized Clinical Trial.” JAMA, October 12, 2023. https://doi.org/10.1001/jama.2023.21019.
Standard protocols also typically include 2 pools of cryoprecipitate (4-g fibrinogen equivalent), added again to the second and subsequent packs. One prehospital helicopter medical service in the UK utilized a combined “RBC and plasma” product and whole blood was available in the US. When transfused, both were recorded as 1 U of RBCs and 1 U of FFP. In the intervention group, patients were to be administered an additional 3 pools of cryoprecipitate (6-g fibrinogen equivalent) as early as possible, with the aim to start within 90 minutes of admission.
68% of patients received their first dose of cryoprecipitate within the study goal of 90 minutes after admission compared with 9% in the standard care group.
Higher mortality in subgroup of penetrating trauma
– Who gets fibrinogen supplementation and should it be in the form of cryo or fibrinogen concentrate
Crytalloids
2 Units in 24 hours
Giving plasma for additional volume resuscitation
Crystalloid causes CRALI
Additional New Information
More on EMCrit
- EMCrit 197 – The Logistics of the Administration of Massive Transfusion(Opens in a new browser tab)
- EMCrit 144 – The PROPPR trial with John Holcomb(Opens in a new browser tab)
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Editor-in-Chief, at EMCrit.org
An ED Intensivist from NY.
Professor
Nassau University Medical Center
No conflicts of interest (coi).
Professor
Nassau University Medical Center
No conflicts of interest (coi).
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I have two comments:
1. Fantastic episode—such a great idea to have John back on to catch up on this stuff.
2. Holy fucking shit time flies!
Sam
Great episode! Unfortunately, there was something (mild) wrong with the sound.
Great episode! Unfortunately, there was something (mild) wrong with the sound.
Great episode, I agree with 95% of what Dr. Holcomb had to say. I believe calcium should be given early and empirically to hypotensive trauma patients on arrival—ideally, 1 gram of calcium chloride with every pack of MTP to prevent profound hypocalcemia. This approach also serves as an antidote for hyperkalemia, which occurs quite frequently in patients receiving MTP. The “lethal diamond” of trauma—which includes the lethal triad of acidosis, coagulopathy, hypothermia, plus hypocalcemia—is very real. There is plenty of data on this topic, including many posts on this blog, particularly by Karim Brohi. The evidence supporting calcium replacement is… Read more »
fantastic points!! and as you know, totally agree with you on the calcium side of things
Fantastic, thanks so much for this episode! Very cool to hear the bit about plasma usage and the 2L limit on crystalloids. Could you recommend some specific articles for this (namely, articles showing benefit when favoring FFP over crystalloids in trauma patients & CRALI harm reduction)? Brief background for my question: The conversation in this episode totally corroborates our clinical practice and experiences in operative anesthesia here at a major German trauma center–namely favoring FFPs and limiting crytalloids in trauma patients (clinically, after giving plasma we see that katecholamines can typically be reduced drastically or weaned completely in a way… Read more »