Pre-hospital intra-osseous freeze dried plasma transfusion: a case report

Massive hemorrhage with coagulopathy is the leading cause of death in combat 1,2]. Human plasma is considered the treatment of choice for severe coagulopathy 3-5].

Fresh Frozen Plasma (FFP) is widely used in the hospital settings for indications
including severe coagulopathy and blood loss due to trauma. The advantages of the
usage of plasma are: 1. Volume replacement 2. Preservation of intra vascular volume
due to plasma proteins 3. PH balanced fluid 4. Replacing and assisting hemostasis
by adding coagulation factors. However, the need for special conditions to store FFP
makes it practically impossible to be used in pre-hospital conditions, especially
in combat settings. Thus, crystalloids or colloids currently serve as the common first
line for volume resuscitation in the pre-hospital arena [ref TCCC, ACLS 6]]. Freeze-Dried Plasma (FDP) can be stored in room temperature, making it suitable
for use in the pre-hospital conditions. FDP was used during World War II by the American
army and others6. However, due to the risk of infection transmission, especially hepatitis,
its use was stopped at 1968. Single donor FDP was introduced in 2007 7]. This product significantly reduced the risk of transmitted infection, by that, transforming
FDP into a safer product 3]. Since, more than 230,000 units of FDP were administered in the hospital setting,
mainly in Germany and France 3]. In vitro analysis of FDP has demonstrated a small decrease in factors V and VIII
(ranging from a 25% decrease to no decrease) when compared with fresh plasma. The
clinical effectiveness and adverse reactions of FDP were found to be very similar
to FFP making it an appropriate alternative 3,8,9]. However, the use of plasma in pre-hospital settings is very restricted with a very
small number of reports found in Pubmed search. These reports mainly describe the
use of plasma in role 3 combat-hospital-facility or during helicopter transport of
wounded to the hospital 1,10]. The only previously reported use of FDP at the point of injury was published by
the Israeli Defense Forces 11-13]. We describe administration of FDP to a 13 years old girl through intra-osseous catheter.