Resuscitation

Liquid Plasma vs FFP: Impact On Your Massive Transfusion Protocol

In my last post, I discussed the growing number of choices for plasma replacement. Today I’ll look at some work that tried to determine whether any one of them is better than the others when used in the massive transfusion protocol (MTP).

As noted last time, fresh-frozen plasma (FFP, frozen within 8 hours) and frozen plasma (FP, frozen within 24 hours) have a shelf life of 5 days once thawed. Liquid plasma (never frozen, LQP) is good for the 21 days after the original unit was donated, plus the same 5 days, for a total of 26 days.

LQP is not used at most US trauma centers. It is more commonly used in Europe, and a study there suggested that the use of thawed plasma increased short-term mortality when compared to liquid plasma. To look at this phenomenon more closely, a group from UTHSC Houston and LSU measured hemostatic profiles in both plasma types at various time points during their useful lives.

All products were analyzed using thromboelastography (TEG) and thrombogram, and platelet count, microparticles, clotting factors, and natural coagulation inhibitors were measured. They chose 10 units of thawed FFP and 10 units of LQP, and assayed them every 5 days during their useful shelf life.

Here are the factoids:

  • Platelet counts were much higher in day 0 LQP (75K) vs day 0 thawed plasma (7.5K). Even at the end of shelf life, the LQP was 1.5x higher than thawed (15K vs 10K).
  • Thrombogram showed that LQP had higher endogenous thrombin production until the end of shelf life
  • TEG demonstrated that LQP had a higher capacity to clot that gradually declined over time. It became similar to thawed plasma at the end of its shelf life.
                         (TEG MA for liquid (LQP) and thawed (TP) plasma
  • Most clotting factors remained stable in LQP, except Factors V and VIII, which slowly declined

Bottom line: Liquid plasma sounds like good stuff, right? Although there are a few flaws in the collection aspect of this study, it provides good evidence that never-frozen plasma has better coagulation properties than thawed plasma. Will this translate into better survival when used in the MTP for trauma? One would think so, but you never really know until you try it. Our hospital blood bank infrastructure isn’t prepared to handle this product yet, for the most part. What we really need is a study that shows the survival advantage of using liquid plasma compared to thawed plasma. But don’t hold your breath. It will take a large number of patients and some fancy statistical analysis to demonstrate this. I think we’ll have to look to our military colleagues to pull this one off!

Reference: Better hemostatic profiles of never-frozen liquid plasma compared with thawed fresh frozen plasma. J Trauma 74(1):84-91, 2013.

Resuscitation

Liquid Plasma vs FFP: Definitions

I’ll spend the next two posts discussing plasma. This is an important component of any trauma center’s massive transfusion protocol (MTP). Coagulopathy is the enemy of any seriously injured patient, and this product is used to attempt to fix that problem.

And now, there are two flavors available: liquid plasma and fresh-frozen plasma. But there is often confusion when discussing these products, especially when there are really three flavors! Let’s review exactly what they are, how they are similar, and how they differ.

Fresh frozen plasma (FFP)
This is plasma that is separated from donated whole blood. It is generally frozen within 8 hours and is called FFP. However, in some cases, it may not be frozen for a few more hours (not to exceed 24 hours total), and in that case, it is called FP24 or FP. It is functionally identical to FFP. But note that the first “F” is missing. Since it has gone beyond the 8-hour mark, it is no longer considered “fresh.” To be useful in your MTP, it must be thawed, which takes 20-40 minutes depending on the technique.

Thawed plasma
Take a frozen unit of FFP or FP, thaw it, and keep it in the refrigerator. Readily available, right? However, the clock starts ticking, and this unit expires after 5 days. Many hospital blood banks keep this product available for the massive transfusion protocol, especially if other hospital services are busy enough to use it as it approaches expiration. Waste is bad and expensive!

Liquid plasma (never frozen)
This is prepared by taking the plasma separated from donated blood and placing it in the refrigerator, not the freezer. Its shelf life is that of the unit of whole blood it was taken from (21 days), plus an additional 5 days, for a total of 26 days. This product used to be a rarity, but is becoming more common because of its longer shelf life than thawed plasma.

Finally, a word on plasma compatibility. ABO compatibility is still a concern, but Rh is not. There are no red cells in the plasma to carry any of the antigens. However, the plasma is loaded with A and/or B antibodies, depending on the donor’s blood type. So the compatibility chart is reversed compared to what you are accustomed to when giving red cells.

Remember, you are delivering antibodies with plasma and not antigens. So a Type A donor will have only Type B antibodies floating around in their plasma. This makes it incompatible with people with blood types B or AB.

Type O red cells are the universal donor type because they have no antigens on their surface. Since Type AB donors have both antigens on their red cells, they have no antibodies in their plasma. This makes AB plasma the universal donor type. Weird, huh? Here’s a compatibility chart for plasma.

Next time, I’ll discuss the virtues of the various plasma types used for massive transfusion in trauma.

Mechanism

Falling Bullets: What Goes Up…

I recently reviewed a case of a person walking outside during fireworks who experienced something strike the top of his head. He could feel something solid stuck in his scalp and thought a piece of a firework had hit him. But then he noticed that people nearby were shooting guns into the air. He also noted a slight weakness and numbness in his upper extremity.

He rapidly proceeded to his local emergency department. Sure enough, physical exam and CT scan revealed a small caliber bullet partially embedded in the top of his skull, with a small contusion in the frontoparietal area. Neurosurgery removed the projectile without incident, and the dura was intact. His neurologic symptoms improved but did not fully disappear before discharge.

This whole situation made me curious. How big a problem is this? How dangerous are bullets fired in the air? The first paper I could find in the trauma literature dates back to 1994 in the Journal of Trauma. The authors presented a series of 118 patients struck by falling projectiles over 10 years. The majority of patients were struck in the head (77%), and the mortality was 32%!

An interesting case report described a male who was watching fireworks who presented to the ED with chest pain and dyspnea.

The terminal velocity of bullets varies based on their size and shape. It ranges from 200-300 ft/sec, or 140-200 mph! Although these numbers are lower than the initial muzzle velocity, they are quite high and comparable to the velocity of a high-powered pellet gun. But with a much heavier projectile. On exam, a penetrating injury was seen above the nipple on the left chest. The abdominal x-ray showed this:

He was taken for laparotomy, and injuries to the splenic hilum, stomach, and diaphragm were identified. Two ventricular injuries were also found and were successfully repaired.

Bottom line: Bullets fired into the air can reach high altitudes and attain high terminal velocities on their descent. The speeds involved can easily pierce bone (e.g., the cranium) and traverse multiple body cavities. Although this activity is universally illegal, it still occurs. Always be wary of this issue during public fireworks celebrations and large family celebrations. Perform a thorough exam of all the nooks and crannies so that these sometimes subtle injuries are identified quickly.

References:

  • Spent bullets and their injuries: the result of firing weapons into the sky. J Trauma. 1994 Dec;37(6):1003-6. PMID: 7996596.
  • Cardiac injury caused by a celebratory bullet. Ann Thorac Surg. 2007 Jan;83(1):283-4. doi: 10.1016/j.athoracsur.2006.04.046. PMID: 17184680.
Resuscitation

Massive Transfusion Cooler Etiquette

The Massive Transfusion Protocol (MTP) is one of the key life-saving tools that trauma professionals can utilize in their trauma centers. These are complex processes with specific triggers and logistics that vary by trauma center level, location, and volume. Because of this complexity, it is impossible to create a cookbook for designing your protocol.

However, there is one constant across all trauma centers regarding their MTP. I call it MTP cooler etiquette. This cooler is the center focus of the entire protocol, and the patient relies on good manners in its use for their life. Here are my thoughts about how to properly handle the MTP cooler.

  • Decide who carries it to and from the trauma bay / OR  ICU. At a few centers, blood bank personnel are responsible for bringing the coolers to the required location. However, the majority do not have enough spare lab techs to run coolers all around the hospital. Each center will need to decide who is best suited. Frequently, this falls to personnel from the ED or OR. However, in large medical complexes, it may be preferable to have security personnel handle this, as they are very familiar with the hospital layout.
  • Ensure the cooler is visible in the area it is used at all times. It is critically important that the cooler not be hidden in a corner or behind other equipment. This can lead to it being forgotten and to the wastage of the blood products inside. In the trauma bay, it should be located next to the team leader. In the operating room, it should be adjacent to anesthesia personnel. In the ICU, it should be located just inside the patient room door. This guarantees that everybody who enters and leaves the area can see it and will not forget to send it back when it’s no longer needed.
  • Place clear signage on the cooler to remind all personnel to call the blood bank when the MTP is over.
  • When moving the patient from area to area, place the cooler on the bed next to them. Placing it under the bed is a recipe for forgetfulness.
  • Empower everyone in the room to bring up the question of whether the cooler is no longer needed. Don’t wait until there are cobwebs on it and the blood products are at room temperature. Once the question is asked, call the blood bank immediately and let them know it is being deactivated.
  • Finally, decide who has the task of taking it back to the blood bank. Typically, this is someone from the area where it was last used. Anyone assigned to this task should recognize the importance of a timely return to the blood bank. Blood is a precious product and should be handled accordingly.

If you have some good suggestions on blood bank etiquette, please leave them in the comments below.

Trauma Center

Secondary Overtriage: Level III vs Nontrauma centers

Secondary overtriage is defined as a trauma patient transfer to a higher-level trauma center where the patient ultimately does not require any major intervention. Frequently, these patients are discharged directly from the receiving hospital’s ED or soon thereafter. The downside of secondary overtriage is that it may unnecessarily use considerable resources at the tertiary center.  This creates a clear drain on the receiving center and contributes to the congestion issues that have been prevalent since the COVID-19 pandemic.

A recent paper examined the impact of trauma center designation for the referring center on patterns of secondary overtriage. Specifically, it examined whether the referring hospital was a designated level three state trauma center or a non-level three center. It was written by the HCA Health Care Center for Trauma and Acute Care Surgery Research in Nashville. The paper focused on resource consumption at the upstream Level I trauma center, including hospital length of stay, intensive care unit length of stay, and average ventilator days.

Here are the factoids:

  • A total of 2,309 inter-facility transfers to a single level one center were analyzed.
  • Transfers from 20 referring non-tertiary facilities over two years were reviewed. Only centers that referred more than 30 patients per year were included (see my comments below). All were part of the same regional trauma system.
  • Five of the referring centers were Level III trauma centers (4 ACS verified in the receiving Level I center’s hospital system, and one center designated by the State of Tennessee).
  • The other 15 were non-Level III centers (Level IV or non-trauma centers).
  • Secondary over triage was formally defined as patients who had no major surgical intervention under anesthesia and 1) were either discharged home directly from the ED within two days or 2) were admitted and discharged alive from the hospital without transfer to hospice within two days.
  • Secondary overtriage occurred in 24% of transfers from a Level III versus 28% of non-Level III transfers. This is statistically significant and indicates that transfer from a non-Level III center is associated with a 31% higher likelihood of secondary overtriage.
  • Mortality rates were similar between the groups,  but transfers from non-Level III centers had shorter hospital, ICU, and ventilator days, which suggested they were lower acuity transfers.

The authors concluded that there is value in the trauma designation requirements and process, which may allow those centers to retain patients who might otherwise be unnecessarily transferred to a higher-level center.

Bottom line: This is an important and well-written paper that addresses the significant issue of secondary overtriage, which occurs frequently every day across this country. It had enough statistical power to identify differences between transfers from trauma and non-trauma centers. 

It does have a few weaknesses, however. As always, a single-center retrospective study raises a few flags, but the statistical power remains significant here. The authors excluded non-trauma centers that referred fewer than 30 patients per year. This could bias the sample toward hospitals that have active referral relationships. I can’t predict the actual impact on their data. Finally, there is no realistic way to capture the actual reason for transfer using registry data. This factor is really unknown in most papers on trauma transfers and hints at the very complex reasons that centers decide to transfer. 

Every state has a verification or designation process for trauma centers. The system exists. The individual hospitals typically decide whether to participate. This paper suggests that all hospitals should participate in a system to the best of their capabilities, so they can optimize patient care and relieve as much strain on the overall system as possible. The next step in research on this topic is to focus on the individual patient impact (and their families) of these potentially unnecessary transfers. 

Reference: Secondary overtriage: impact of trauma center designation and trauma system integration. Trauma Surg Acute Care Open. 2026 Feb 23;11(1):e002027. doi: 10.1136/tsaco-2025-002027. PMID: 41743404; PMCID: PMC12931552.

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