Updates on Hemostatic Strategies in Acute Trauma: Use of Whole Blood, Tranexamic Acid and Fibrinogen Replacement

Scientific findings continue to advance the field of resuscitation and management of bleeding and coagulopathy in civilian patients with acute trauma although the proportion of randomized controlled studies is limited. Three topical and clinically relevant interventions in acute trauma include: 1. Use of low titer whole blood in place of or in combination with component therapy, 2. Indications, timing and potential concerns with timely administration of tranexamic acid and 3. Approaches to fibrinogen supplementation, either with cryoprecipitate or fibrinogen concentrate. These topics were presented within the last 3–5 years in this journal and there has been sufficient new peer-reviewed data published to support an updated review. In this narrative, we summarize clinical findings from 2022 and 2023, including the few prospective, randomized studies along with observational, retrospective reports. With the new data, we make updated recommendations for these 3 treatment options for the clinician caring for the severely injured trauma patient.

Early administration of low titer whole blood has been shown to have short-term and medium-term mortality benefit compared to component therapy for severely injured trauma patients in multiple retrospective and prospective studies, although results are mixed. The risk of harm of low titer whole blood is low. Although recent prospective and retrospective studies regarding the use of tranexamic acid (TXA) for severely injured trauma patients show mixed results, recent meta-analyses suggest early administration of TXA in severely injured trauma patients has favorable effects on transfusion requirements and short-term and medium-term mortality. Fibrinogen replacement in the form of fibrinogen concentrate and cryoprecipitate has been shown to decrease blood loss from severe trauma in both retrospective and prospective studies, although no mortality benefits have been demonstrated. Empiric administration of cryoprecipitate has not been shown to improve mortality compared to standard massive transfusion protocol, although the risk of administration is low.

Severely injured trauma patients should receive early administration of low titer whole blood when available. TXA should be given in severe trauma, ideally within 1 h but not greater than 3 h after injury. Fibrinogen replacement with either fibrinogen concentrate or cryoprecipitate should be considered in severe trauma to reduce blood loss, especially in the setting of hypofibrinogenemia, although mortality benefit has yet to be shown.