Earlier FFP Administration for Hemorrhagic Shock

What do 61-year-old Joyce Richardson of White Pigeon and 17-year-old Cody Miller of Constantine have in common?  Both recently received the lifesaving blood component fresh frozen plasma (FFP) to help stop uncontrolled bleeding very early in their care, thanks to the quick thinking and cooperation of providers at Three Rivers Health and West Michigan Air Care.  

Joyce Richardson came to Three Rivers Health on October 31st in acute hemorrhagic shock with internal and gastrointestinal bleeding associated with her prescription blood-thinner, Coumadin.  Upon Air Care's arrival, the nursing staff at Three Rivers initiated FFP to reverse bleeding.  Joyce was flown to Borgess Medical Center receiving a total of 2 units of FFP before arrival.  With Adrian, her husband of 43 years at her side, she eventually recovered and was discharged after a 19-day stay.

Just a few days after Joyce's flight with Air Care, Cody Miller arrived at Three Rivers Health bleeding from his tonsillectomy surgical site performed a week prior at an out-of-state facility. The ER staff of Three Rivers Health removed several clots from Cody's airway before rushing him to the operating room (OR) to control a small arterial bleed. Cody was intubated and Dr. Akiyoshi Kido used tonsil packing to control the bleeding as West Michigan Air Care arrived.  A unit of uncrossmatched packed red blood cells (PRBCs) was initiated to replace Cody's 1.5-liter blood loss and uncrossmatched FFP was also handed to the Air Care crew as they departed for Bronson to begin en route.  After a few crucial stitches in Bronson's OR, Cody was extubated and able to go home 2 days later.  

What is remarkable about the initial care Cody and Joyce received is that they both benefited from the rapid administration of FFP at their sending institution. Many physicians and nurses are unaware that blood banks can dispense uncrossmatched FFP; they simply need a 20-30 minute head start for thawing. With enough notice uncrossmatched FFP can be waiting for the hemorrhagic shock patient as that patient arrives at a receiving institution.  In the interest of conserving adequate stores of FFP, however, it remains vitally important for physicians to confirm the patient's condition before ordering it.

FFP for Coumadin reversal has long been a standard of care, but it was only recently demonstrated that a PRBC:FFP transfusion ratio of 1:1 supported outcomes in combat casualties with hemorrhagic shock (Beekley, 2008). Air Care's protocols are grounded in evidence-based research and we have adopted this ratio with the support of Borgess and Bronson Trauma Services. Dr. Scott Davidson, Bronson's Dir. of Trauma Svcs. and Lt. Col. in the US Air Force Reserves used this approach during his deployment to a Combat Support Hospital in Iraq with good success. "Using this ratio we avoided some of the complications associated with large-volume crystalloid resuscitation," he said. The strategy makes sense because PRBCs and crystalloid do not replace clotting factors; FFP does. Additionally, blood loss can be reduced by titrating its replacement to keep systolic blood pressure >80 mm Hg in patients without neurologic complications (Geeraedts, Kaasjager et al, 2009).

These days Cody is back at basketball practice and celebrated his 18th birthday on December 7th.  Joyce Richardson is home working with therapists and her husband to get back into her routine.  Both former patients wish to express their gratitude to all the providers that helped them, and their families echo the same sentiments.  "We couldn't have asked for any better care," said Adrian.

By Dawn Johnston, RN, NREMT-P, CFRN
Flight Nurse
West Michigan Air Care

Beekley, A.C. (2008).  Damage control resuscitation: A sensible approach to the exsanguinating surgical patient. Critical Care Medicine, 36 (7), s267-s274.

Geeraedts, Jr., L. M. G., Kaasjager, H. A. H. et al (2009).  Exsanguination in trauma: A review of diagnostics and treatment options. Injury: International Journal of the Care of the Injured, 40 (1): 11-20.

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