State of the Evidence for Prehospital Plasma Infusion for Patients with Suspected Traumatic Hemorrhage: A Rapid Review by the Prehospital Evidence-Based Practice Program (PEP)

State of the evidence for prehospital plasma infusion for patients with suspected traumatic hemorrhage: A rapid review by the Prehospital Evidence-Based Practice Program (PEP)

Introduction: Hemorrhage is the leading cause of preventable death within the first 24 hours of injury and up to 50% of those deaths happen in the prehospital setting. Early replacement of volume and clotting factors is critical. 

Objective: The objective of this rapid systematic review was to evaluate the outcomes related to the administration of plasma to patients with suspected traumatic hemorrhage in the prehospital environment.

Methods: PubMed was searched for research meeting the inclusion criteria. Screening, full text review, data extraction and critical appraisal were completed in duplicate. We report on each study’s demographics, setting and outcomes using the PEP Level and Direction of Evidence matrix (LOE/DOE). 

RESULTS: Forty-three studies were included in the analysis. Most studies were randomized controlled trials (RCT) or RCT re-analyses resulting in 42% of the included studies being LOE I. Over half were from the United States (55%) and reported on services with a critical care paramedic/nurse crew configuration (51%) delivering thawed plasma (47%) in an Air Medical Critical Care Transport (CCT) setting (63%) to adults (77%) on scene (44%). The delivery of prehospital plasma was supported by the evidence for the primary outcome of mortality in 73% of studies. The most reported primary outcome mortality timeframe was 30-day mortality (n=8). Seven of the eight studies reporting on 30-day mortality were LOE I, each finding a positive impact on 30-day mortality for a range of patient presentations. There were (n=13, 1.02%) total adverse events reported across all included studies. The patient related proxy measures held a supportive or neutral position except in one case. It was found in a reanalysis of RCT data, that plasma delivery was negatively associated with the incidence of hypocalcaemia. Prehospital plasma delivery was found to be feasible for all the primary feasibility outcomes. Its use was found to be cost-effectiveness, although wastage may be a concern. 

Conclusion: High quality evidence supports the delivery of plasma in the CCT prehospital setting for improvement of 30-mortality for multiple patient presentations. Plasma as part of a robust Damage Control Resuscitation strategy by CCT providers is feasible, safe, and cost-effective.