Association of Prehospital Plasma With Survival in Patients With Traumatic Brain Injury

Abstract

IMPORTANCE Prehospital plasma administration improves survival in injured patients at risk for hemorrhagic shock and transported by air ambulance. Traumatic brain injury (TBI) is a leading cause of death following trauma, but few early interventions improve outcomes. OBJECTIVE To assess the association between prehospital plasma and survival in patients with TBI. DESIGN, SETTING, AND PARTICIPANTS The Prehospital Air Medical Plasma (PAMPer) trial was a pragmatic, multicenter, phase 3, cluster randomized clinical trial involving injured patients who were at risk for hemorrhagic shock during air medical transport to a trauma center. The trial was conducted at 6 US sites with 9 level-I trauma centers (comprising 27 helicopter emergency services bases). The original trial analyzed 501 patients, including 230 patients who were randomized to receive plasma and 271 randomized to standard care resuscitation. This secondary analysis of a predefined subgroup included patients with TBI. Data analysis was performed from October 2019 to February 2020. INTERVENTIONS Patients were randomized to receive standard care fluid resuscitation or 2 units of thawed plasma. MAIN OUTCOMES AND MEASURES The primary outcome was mortality at 30 days. Patients with TBI were prespecified as a subgroup for secondary analysis and for measurement of markers of brain injury. The 30-day survival benefit of prehospital plasma in subgroups with and without TBI as diagnosed by computed tomography was characterized using Kaplan-Meier survival analysis and Cox proportional hazard regression. RESULTS In total, 166 patients had TBI (median [interquartile range] age, 43.00 [25.00-59.75] years; 125 men [75.3%]). When compared with the 92 patients who received standard care, the 74 patients with TBI who received prehospital plasma had improved 30-day survival even after adjustment for multiple confounders and assessment of the degree of brain injury with clinical variables and biomarkers (hazard ratio [HR], 0.55; 95% CI, 0.33-0.94; P = .03). Receipt of prehospital plasma was associated with improved survival among patients with TBI with a prehospital Glasgow Coma Scale score of less than 8 (HR, 0.56; 95% CI, 0.35-0.91) and those with polytrauma (HR, 0.50; 95% CI, 0.28-0.89). Patients with TBI transported from the scene of injury had improved survival following prehospital plasma administration (HR, 0.45; 95% CI, 0.26-0.80; P = .005), whereas patients who were transferred from an outside hospital showed no difference in survival for the plasma intervention (HR, 1.00; 95% CI, 0.33-3.00; P = .99).

Präklinische Therapie mit Blutprodukten – das Projekt „HeliBlut“

“…Bezüglich der kompromittierten Gerinnung des Traumapatienten zeigte die innerklinische Gabe von Plasma eine verminderte traumaassoziierte Koagulopathie und einen verbesserten pH-Wert [16,17]; auch bei polytraumatisierten Patienten mit Schädel-Hirn-Trauma scheint ein Benefit zu bestehen [18].…”

Traumatic Brain Injury—A Review of Intravenous Fluid Therapy

“…Additionally, transport origin (scene of accident vs. hospital transfer) was used as a proxy for time-to-plasma resuscitation. When grouped by transport origin, patients transported from the scene of the accident who received plasma had lower 30-day mortality than those who did not receive plasma, while there was no difference between patients receiving plasma vs. no plasma when transported from a referral emergency department, suggesting that minimizing time from injury to administration may be important (46).…”

“…Gruen (46) et al reported the secondary analysis of a predefined subgroup of patients with TBI from the PAMPer trial. The PAMPer trial ( 52) was a multi-center, clusterrandomized, phase-3 superiority clinical trial comparing plasma administration to standard-care resuscitation in severely injured patients during air-medical transport, and the primary outcome was mortality at 30 days.…”

Plasma as a resuscitation fluid for volume‐depleted shock: Potential benefits and risks

“…As these markers were reduced long after the resuscitation had ceased, preservation of the glycocalix seems a likely mechanism of the beneficial effects of prehospital plasma. Of interest, the benefit of prehospital plasma was also shown for the subgroup of TBI patients 32 . Although mechanisms are not clear, benefits of plasma in the specific setting of TBI may not be related to volume expansion but again to a reduction of endothelial dysfunction, 31 which may have contributed to preservation of the blood brain barrier.…”

“…Of interest, the benefit of prehospital plasma was also shown for the subgroup of TBI patients. 32 Although mechanisms are not clear, benefits of plasma in the specific setting of TBI may not be related to volume expansion but again to a reduction of endothelial dysfunction, 31 which may have contributed to preservation of the blood brain barrier. The benefit of plasma may also relate to the duration of shock and hence the severity of endothelial injury, given that plasma may be particularly beneficial in patients with long transport times to the hospital.…”