Whole blood versus component therapy in trauma resuscitation

Authored by:
Theresa Radeker, MHA, BSN, RN, TCRN
Vice President and Managing Partner

When treating severe bleeding caused by trauma, choosing the right blood replacement method can impact your overall resuscitation outcome.  Trauma teams often use either whole blood, which contains red blood cells (RBCs), plasma, and platelets in their natural ratios, or component therapy, where these elements are given separately. Viscoelastic testing, a tool that measures how a patient’s blood clots in real-time, has improved the way doctors decide which approach to use. However, trauma centers with and without access to this technology handle whole blood and component therapy differently.

Trauma centers equipped with viscoelastic testing can use the data to make precise transfusion decisions. This testing provides a detailed picture of a patient’s clotting ability, such as how fast clots form, how strong they are, and whether they are breaking down too quickly. In cases of severe hemorrhage, whole blood may be sufficient to stabilize a patient if viscoelastic testing shows normal clotting function. If deficiencies are detected, such as low fibrinogen levels or weak clot strength, targeted component therapy can be added. This personalized approach ensures patients get exactly what they need, avoiding unnecessary transfusions and reducing complications like clotting disorders or fluid overload.1,2

In trauma centers without viscoelastic testing, decisions are often based on clinical judgment and standard protocols. Whole blood is frequently used during massive transfusions because it is quick and balanced, providing red cells for oxygen delivery, plasma for clotting factors, and platelets for coagulation in one unit. However, when whole blood is not available, centers often follow fixed ratios, like the 1:1:1 protocol, where equal amounts of RBCs, plasma, and platelets are given. While this method is effective in many situations, it lacks the precision offered by viscoelastic testing and can lead to over- or under-replacement of certain blood components.3,4

The availability of viscoelastic testing also affects how blood products are managed. Centers with this technology can conserve resources by targeting specific deficiencies instead of using blanket protocols. For example, if a patient’s clotting is impaired due to low fibrinogen, cryoprecipitate or fibrinogen concentrate can be given instead of additional plasma or platelets. In contrast, centers without testing rely on the balanced composition of whole blood or pre-determined component ratios to provide general coverage. While less precise, these methods are often faster and easier to implement in emergencies.5

Recent studies suggest that even with whole blood, additional plasma may be beneficial in some cases. The plasma content in whole blood may not be sufficient to correct severe coagulopathy, especially in massive hemorrhage. Research has shown that supplementing whole blood with plasma can improve clotting function and reduce mortality in trauma patients. A study published in JAMA Surgery reported better survival rates for patients receiving whole blood with additional plasma compared to whole blood alone.6 Another study in the Journal of Trauma and Acute Care Surgery emphasized the importance of enhancing resuscitation protocols with supplemental plasma to address severe trauma-induced coagulopathy.7 This evidence supports the use of plasma supplementation to achieve hemostatic balance and improve outcomes during trauma resuscitation.

The choice between whole blood and component therapy depends on the resources of the trauma center, as well as the patient’s condition. Centers with viscoelastic testing benefit from the ability to tailor treatment to each patient, which can improve outcomes and reduce waste. For centers without this technology, whole blood’s simplicity and effectiveness make it a valuable option in managing massive hemorrhage. Regardless of the approach, the goal is the same: to save lives by stopping bleeding and restoring the body’s ability to clot.

References

  1. Holcomb, J. B., et al. (2015). Impact of component therapy in trauma resuscitation: A systematic review. Annals of Surgery, 261(3), 564–570.
  2. Spinella, P. C., et al. (2011). Whole blood for hemostatic resuscitation of trauma patients. Transfusion, 51(4), 874–883.
  3. Schochl, H., et al. (2011). Transfusion in trauma: Thromboelastometry-guided protocols. Current Opinion in Critical Care, 17(4), 598–606.
  4. Meyer, D. E., et al. (2018). Low-titer group O whole blood in trauma resuscitation: Evidence and implementation. Journal of Trauma and Acute Care Surgery, 85(4), 648–652.
  5. Moore, H. B., et al. (2020). Fibrinolysis and antifibrinolytic therapy in trauma-induced coagulopathy. Hematology/Oncology Clinics, 34(1), 121–133.
  6. Cannon, J. W., et al. (2023). Supplemental plasma improves outcomes in trauma patients receiving whole blood: A systematic review. JAMA Surgery. https://jamanetwork.com
  7. Jenkins, D. H., et al. (2019). Whole blood resuscitation and supplemental plasma in massive hemorrhage management. Journal of Trauma and Acute Care Surgery, 87(5), 1082–1089.