Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial

doi:10.1001/jama.2015.12

Clinical Trial

. 2015 Feb 3;313(5):471-82.

doi: 10.1001/jama.2015.12.

Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial

John B Holcomb¹, Barbara C Tilley², Sarah Baraniuk², Erin E Fox¹, Charles E Wade¹, Jeanette M Podbielski¹, Deborah J del Junco¹, Karen J Brasel³, Eileen M Bulger⁴, Rachael A Callcut⁵, Mitchell Jay Cohen⁵, Bryan A Cotton¹, Timothy C Fabian⁶, Kenji Inaba⁷, Jeffrey D Kerby⁸, Peter Muskat⁹, Terence O'Keeffe¹⁰, Sandro Rizoli¹¹, Bryce R H Robinson¹², Thomas M Scalea¹³, Martin A Schreiber¹⁴, Deborah M Stein¹³, Jordan A Weinberg⁶, Jeannie L Callum¹⁵, John R Hess¹⁶, Nena Matijevic¹, Christopher N Miller¹⁷, Jean-Francois Pittet¹⁸, David B Hoyt¹⁹, Gail D Pearson²⁰, Brian Leroux²¹, Gerald van Belle²²; PROPPR Study Group

Collaborators, Affiliations

Collaborators

PROPPR Study Group:
John B Holcomb, Charles E Wade, Deborah J del Junco, Erin E Fox, Nena Matijevic, Jeanette M Podbielski, Angela M Beeler, Barbara C Tilley, Sarah Baraniuk, Stacia M DeSantis, Hongjian Zhu, Joshua Nixon, Roann Seay, Savitri N Appana, Hui Yang, Michael O Gonzalez, Lisa Baer, Yao-Wei Willa Wang, Brittany S Hula, Elena Espino, An Nguyen, Nicholas Pawelczyk, Kisha D Arora-Nutall, Rishika Sharma, Jessica C Cardenas, Elaheh Rahbar, Tyrone Burnett Jr, David Clark, Gerald van Belle, Susanne May, Brian Leroux, David Hoyt, Judy Powell, Kellie Sheehan, Alan Hubbard, Adam P Arkin, John R Hess, Jeannie L Callum, Jean-Francois Pittet, Christopher N Miller, Bryan A Cotton, Laura Vincent, Timothy Welch, Tiffany Poole, Evan G Pivalizza, Sam D Gumbert, Yu Bai, James J McCarthy, Amy Noland, Rhonda Hobbs, Eileen M Bulger, Patricia Klotz, Lindsay Cattin, Keir J Warner, Angela Wilson, David Boman, Nathan White, Andreas Grabinsky, Jennifer A Daniel-Johnson, Mitchell Jay Cohen, Rachael A Callcut, Mary Nelson, Brittney Redick, Amanda Conroy, Marc P Steurer, Preston C Maxim, Eberhard Fiebig, Joanne Moore, Eireen Mallari, Peter Muskat, Jay A Johannigman, Bryce R H Robinson, Richard D Branson, Dina Gomaa, Christopher Barczak, Suzanne Bennett, Patricia M Carey, Helen Hancock, Carolina Rodriguez, Kenji Inaba, Jay G Zhu, Monica D Wong, Michael Menchine, Kelly Katzberg, Sean O Henderson, Rodney McKeever, Ira A Shulman, Janice M Nelson, Christopher W Tuma, Cheryl Y Matsushita, Thomas M Scalea, Deborah M Stein, Cynthia K Shaffer, Christine Wade, Anthony V Herrera, Seeta Kallam, Sarah E Wade, Samuel M Galvagno Jr, Magali J Fontaine, Janice M Hunt, Rhonda K Cooke, Timothy C Fabian, Jordan A Weinberg, Martin A Croce, Suzanne Wilson, Stephanie Panzer-Baggett, Lynda Waddle-Smith, Sherri Flax, Karen J Brasel, Pamela Walsh, David Milia, Allia Nelson, Olga Kaslow, Tom P Aufderheide, Jerome L Gottschall, Erica Carpenter, Terence O'Keeffe, Laurel L Rokowski, Kurt R Denninghoff, Daniel T Redford, Deborah J Novak, Susan Knoll, Jeffrey D Kerby, Patrick L Bosarge, Albert T Pierce, Carolyn R Williams, Shannon W Stephens, Henry E Wang, Marisa B Marques, Martin A Schreiber, Jennifer M Watters, Samantha J Underwood, Tahnee Groat, Craig Newgard, Matthias Merkel, Richard M Scanlan, Beth Miller, Sandro Rizoli, Homer Tien, Barto Nascimento, Sandy Trpcic, Skeeta Sobrian-Couroux, Marciano Reis, Adic Pérez, Susan E Belo, Lisa Merkley, Connie Colavecchia

Affiliations

¹ Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center, Houston.
² Division of Biostatistics, School of Public Health, University of Texas Health Science Center, Houston.
³ Division of Trauma and Critical Care, Department of Surgery, Medical College of Wisconsin, Milwaukee22Dr Brasel is now with the Division of Trauma, Critical Care and Acute Care Surgery, School of Medicine, Oregon Health & Science University, Portland.
⁴ Division of Trauma and Critical Care, Department of Surgery, School of Medicine, University of Washington, Seattle.
⁵ Division of General Surgery, Department of Surgery, School of Medicine, University of California, San Francisco.
⁶ Division of Trauma and Surgical Critical Care, Department of Surgery, College of Medicine, University of Tennessee Health Science Center, Memphis.
⁷ Division of Trauma and Critical Care, University of Southern California, Los Angeles.
⁸ Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, School of Medicine, University of Alabama, Birmingham.
⁹ Division of Trauma/Critical Care, Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio23Dr Muskat is now with the Division of General Surgery, Department of Surgery, School of Medicine, University of California, San Franc.
¹⁰ Division of Trauma, Critical Care and Emergency Surgery, Department of Surgery, University of Arizona, Tucson.
¹¹ Trauma and Acute Care Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
¹² Division of Trauma/Critical Care, Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio.
¹³ R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore.
¹⁴ Division of Trauma, Critical Care and Acute Care Surgery, School of Medicine, Oregon Health & Science University, Portland.
¹⁵ Sunnybrook Research Institute, Department of Clinical Pathology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
¹⁶ Department of Laboratory Medicine, School of Medicine, University of Washington, Seattle.
¹⁷ Department of Emergency Medicine, College of Medicine, University of Cincinnati, Cincinnati, Ohio.
¹⁸ Division of Critical Care and Perioperative Medicine, Department of Anesthesiology, School of Medicine, University of Alabama, Birmingham.
¹⁹ American College of Surgeons, Chicago, Illinois.
²⁰ Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland.
²¹ Department of Biostatistics, School of Public Health, University of Washington, Seattle.
²² Department of Biostatistics, School of Public Health, University of Washington, Seattle21Department of Environmental and Occupational Health Sciences, School of Public Health, University of Washington, Seattle.

PMID: 25647203
PMCID: PMC4374744
DOI: 10.1001/jama.2015.12

Clinical Trial

Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial

John B Holcomb et al. JAMA. 2015.

. 2015 Feb 3;313(5):471-82.

doi: 10.1001/jama.2015.12.

Authors

Collaborators

PROPPR Study Group:
John B Holcomb, Charles E Wade, Deborah J del Junco, Erin E Fox, Nena Matijevic, Jeanette M Podbielski, Angela M Beeler, Barbara C Tilley, Sarah Baraniuk, Stacia M DeSantis, Hongjian Zhu, Joshua Nixon, Roann Seay, Savitri N Appana, Hui Yang, Michael O Gonzalez, Lisa Baer, Yao-Wei Willa Wang, Brittany S Hula, Elena Espino, An Nguyen, Nicholas Pawelczyk, Kisha D Arora-Nutall, Rishika Sharma, Jessica C Cardenas, Elaheh Rahbar, Tyrone Burnett Jr, David Clark, Gerald van Belle, Susanne May, Brian Leroux, David Hoyt, Judy Powell, Kellie Sheehan, Alan Hubbard, Adam P Arkin, John R Hess, Jeannie L Callum, Jean-Francois Pittet, Christopher N Miller, Bryan A Cotton, Laura Vincent, Timothy Welch, Tiffany Poole, Evan G Pivalizza, Sam D Gumbert, Yu Bai, James J McCarthy, Amy Noland, Rhonda Hobbs, Eileen M Bulger, Patricia Klotz, Lindsay Cattin, Keir J Warner, Angela Wilson, David Boman, Nathan White, Andreas Grabinsky, Jennifer A Daniel-Johnson, Mitchell Jay Cohen, Rachael A Callcut, Mary Nelson, Brittney Redick, Amanda Conroy, Marc P Steurer, Preston C Maxim, Eberhard Fiebig, Joanne Moore, Eireen Mallari, Peter Muskat, Jay A Johannigman, Bryce R H Robinson, Richard D Branson, Dina Gomaa, Christopher Barczak, Suzanne Bennett, Patricia M Carey, Helen Hancock, Carolina Rodriguez, Kenji Inaba, Jay G Zhu, Monica D Wong, Michael Menchine, Kelly Katzberg, Sean O Henderson, Rodney McKeever, Ira A Shulman, Janice M Nelson, Christopher W Tuma, Cheryl Y Matsushita, Thomas M Scalea, Deborah M Stein, Cynthia K Shaffer, Christine Wade, Anthony V Herrera, Seeta Kallam, Sarah E Wade, Samuel M Galvagno Jr, Magali J Fontaine, Janice M Hunt, Rhonda K Cooke, Timothy C Fabian, Jordan A Weinberg, Martin A Croce, Suzanne Wilson, Stephanie Panzer-Baggett, Lynda Waddle-Smith, Sherri Flax, Karen J Brasel, Pamela Walsh, David Milia, Allia Nelson, Olga Kaslow, Tom P Aufderheide, Jerome L Gottschall, Erica Carpenter, Terence O'Keeffe, Laurel L Rokowski, Kurt R Denninghoff, Daniel T Redford, Deborah J Novak, Susan Knoll, Jeffrey D Kerby, Patrick L Bosarge, Albert T Pierce, Carolyn R Williams, Shannon W Stephens, Henry E Wang, Marisa B Marques, Martin A Schreiber, Jennifer M Watters, Samantha J Underwood, Tahnee Groat, Craig Newgard, Matthias Merkel, Richard M Scanlan, Beth Miller, Sandro Rizoli, Homer Tien, Barto Nascimento, Sandy Trpcic, Skeeta Sobrian-Couroux, Marciano Reis, Adic Pérez, Susan E Belo, Lisa Merkley, Connie Colavecchia

Affiliations

¹ Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center, Houston.
² Division of Biostatistics, School of Public Health, University of Texas Health Science Center, Houston.
³ Division of Trauma and Critical Care, Department of Surgery, Medical College of Wisconsin, Milwaukee22Dr Brasel is now with the Division of Trauma, Critical Care and Acute Care Surgery, School of Medicine, Oregon Health & Science University, Portland.
⁴ Division of Trauma and Critical Care, Department of Surgery, School of Medicine, University of Washington, Seattle.
⁵ Division of General Surgery, Department of Surgery, School of Medicine, University of California, San Francisco.
⁶ Division of Trauma and Surgical Critical Care, Department of Surgery, College of Medicine, University of Tennessee Health Science Center, Memphis.
⁷ Division of Trauma and Critical Care, University of Southern California, Los Angeles.
⁸ Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, School of Medicine, University of Alabama, Birmingham.
⁹ Division of Trauma/Critical Care, Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio23Dr Muskat is now with the Division of General Surgery, Department of Surgery, School of Medicine, University of California, San Franc.
¹⁰ Division of Trauma, Critical Care and Emergency Surgery, Department of Surgery, University of Arizona, Tucson.
¹¹ Trauma and Acute Care Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
¹² Division of Trauma/Critical Care, Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio.
¹³ R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore.
¹⁴ Division of Trauma, Critical Care and Acute Care Surgery, School of Medicine, Oregon Health & Science University, Portland.
¹⁵ Sunnybrook Research Institute, Department of Clinical Pathology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
¹⁶ Department of Laboratory Medicine, School of Medicine, University of Washington, Seattle.
¹⁷ Department of Emergency Medicine, College of Medicine, University of Cincinnati, Cincinnati, Ohio.
¹⁸ Division of Critical Care and Perioperative Medicine, Department of Anesthesiology, School of Medicine, University of Alabama, Birmingham.
¹⁹ American College of Surgeons, Chicago, Illinois.
²⁰ Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland.
²¹ Department of Biostatistics, School of Public Health, University of Washington, Seattle.
²² Department of Biostatistics, School of Public Health, University of Washington, Seattle21Department of Environmental and Occupational Health Sciences, School of Public Health, University of Washington, Seattle.

PMID: 25647203
PMCID: PMC4374744
DOI: 10.1001/jama.2015.12

Abstract

Importance: Severely injured patients experiencing hemorrhagic shock often require massive transfusion. Earlier transfusion with higher blood product ratios (plasma, platelets, and red blood cells), defined as damage control resuscitation, has been associated with improved outcomes; however, there have been no large multicenter clinical trials.

Objective: To determine the effectiveness and safety of transfusing patients with severe trauma and major bleeding using plasma, platelets, and red blood cells in a 1:1:1 ratio compared with a 1:1:2 ratio.

Design, setting, and participants: Pragmatic, phase 3, multisite, randomized clinical trial of 680 severely injured patients who arrived at 1 of 12 level I trauma centers in North America directly from the scene and were predicted to require massive transfusion between August 2012 and December 2013.

Interventions: Blood product ratios of 1:1:1 (338 patients) vs 1:1:2 (342 patients) during active resuscitation in addition to all local standard-of-care interventions (uncontrolled).

Main outcomes and measures: Primary outcomes were 24-hour and 30-day all-cause mortality. Prespecified ancillary outcomes included time to hemostasis, blood product volumes transfused, complications, incidence of surgical procedures, and functional status.

Results: No significant differences were detected in mortality at 24 hours (12.7% in 1:1:1 group vs 17.0% in 1:1:2 group; difference, -4.2% [95% CI, -9.6% to 1.1%]; P = .12) or at 30 days (22.4% vs 26.1%, respectively; difference, -3.7% [95% CI, -10.2% to 2.7%]; P = .26). Exsanguination, which was the predominant cause of death within the first 24 hours, was significantly decreased in the 1:1:1 group (9.2% vs 14.6% in 1:1:2 group; difference, -5.4% [95% CI, -10.4% to -0.5%]; P = .03). More patients in the 1:1:1 group achieved hemostasis than in the 1:1:2 group (86% vs 78%, respectively; P = .006). Despite the 1:1:1 group receiving more plasma (median of 7 U vs 5 U, P < .001) and platelets (12 U vs 6 U, P < .001) and similar amounts of red blood cells (9 U) over the first 24 hours, no differences between the 2 groups were found for the 23 prespecified complications, including acute respiratory distress syndrome, multiple organ failure, venous thromboembolism, sepsis, and transfusion-related complications.

Conclusions and relevance: Among patients with severe trauma and major bleeding, early administration of plasma, platelets, and red blood cells in a 1:1:1 ratio compared with a 1:1:2 ratio did not result in significant differences in mortality at 24 hours or at 30 days. However, more patients in the 1:1:1 group achieved hemostasis and fewer experienced death due to exsanguination by 24 hours. Even though there was an increased use of plasma and platelets transfused in the 1:1:1 group, no other safety differences were identified between the 2 groups.

Trial registration: clinicaltrials.gov Identifier: NCT01545232.

PubMed Disclaimer

Conflict of interest statement

Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Rizoli reported receiving grant funding from TEM International and CSL Behring. Dr Stein reported serving as an advisor for Decisio Health for which she receives travel reimbursement. No other disclosures were reported.

Figures

**Figure 1. Flow of Patients in the Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) Trial**
CPR indicates cardiopulmonary resuscitation; ED, emergency department; RBC, red blood cell. ^aIncluded patients with the following: 6 known pregnancies, 5 with physicians who refused to randomize, 4 with known do-not-resuscitate order prior to randomization, 3 with burns covering more than 20% of total body surface area, 1 with a documented inhalation injury, 1 who opted out upon arrival to the ED, 1 unknown reason. ^bThe vital statistic data were obtained for patients who withdrew consent when available. Patients who withdrew consent at 24 hours are included in the count of those who withdrew at 30 days.

**Figure 2. Kaplan-Meier Failure Curves for Mortality at 24 Hours and 30 Days**
The colored areas indicate 95% confidence bands, which were calculated using the Hall-Wellner method. The Hall-Wellner bands extend to the last event (death) in each group. For 24-hour mortality, the Cox proportional hazards regression model, adjusted for site as a random effect, produced a hazard ratio (HR) of 0.72 (95% CI, 0.49–1.07). There were no patients lost to follow-up during the first 24 hours from randomization. For 30-day mortality, the Cox proportional hazards regression model, adjusted for site as a random effect, produced an HR of 0.83 (95% CI, 0.61–1.12). Between 24 hours and 30 days, 4 patients were lost to follow-up and were censored when they withdrew consent or were last known to be alive (3 in the 1:1:1 group and 1 in the 1:1:2 group).

**Figure 3. Distribution of Cumulative Blood Product Ratios Within Period up to 24 Hours After Admission**
Prerandomization blood products include those given prior to hospital arrival. Patients who received no red blood cells (RBCs) within an interval were excluded because RBCs are in the ratio denominator. The lower and upper edges of the boxes are the 25th and 75th percentiles, the whiskers extend to ±1.5 × the interquartile range, and the points outside are the outliers. The thick line inside the box represents the median and the circle is the mean.

**Figure 4. Distribution of Blood Product Amounts Within Period up to 24 Hours After Admission**
Prerandomization blood products include those given prior to hospital arrival. The lower and upper edges of the boxes are the 25th and 75th percentiles, the whiskers extend to ±1.5 × the interquartile range, and the points outside are the outliers. The thick line inside the box represents the median and the circle is the mean. Five or 6 U pools of whole blood–derived platelets were considered equivalent to 1 U of apheresis platelets (eg, an adult dose of platelets).

See this image and copyright information in PMC

Comment in

Mortality and ratio of blood products used in patients with severe trauma.
Moore HB, Moore EE, Gonzalez E. Moore HB, et al. JAMA. 2015 May 26;313(20):2077. doi: 10.1001/jama.2015.4418. JAMA. 2015. PMID: 26010639 No abstract available.
Mortality and ratio of blood products used in patients with severe trauma.
McCurdy MT, Liew-Spilger A, Walsh M. McCurdy MT, et al. JAMA. 2015 May 26;313(20):2077-8. doi: 10.1001/jama.2015.4421. JAMA. 2015. PMID: 26010640 No abstract available.
Mortality and ratio of blood products used in patients with severe trauma.
Helwani MA, Gillihan JR. Helwani MA, et al. JAMA. 2015 May 26;313(20):2078. doi: 10.1001/jama.2015.4424. JAMA. 2015. PMID: 26010641 No abstract available.
Mortality and ratio of blood products used in patients with severe trauma--reply.
Holcomb JB, Fox EE, Wade CE; PROPPR Study Group. Holcomb JB, et al. JAMA. 2015 May 26;313(20):2078-9. doi: 10.1001/jama.2015.4427. JAMA. 2015. PMID: 26010642 Free PMC article. No abstract available.
Comparison of video laryngoscopy versus direct laryngoscopy during urgent endotracheal intubation; trial of the route of early nutritional support in critically ill adults; and transfusion of plasma, platelets, and red blood cells in a 1:1:1 versus a 1:1:2 ratio and mortality in patients with severe trauma.
Rali P, Arshad H, Lamba T. Rali P, et al. Am J Respir Crit Care Med. 2015 Oct 1;192(7):892-4. doi: 10.1164/rccm.201504-0691RR. Am J Respir Crit Care Med. 2015. PMID: 26275119 No abstract available.
Response to: "Misunderstanding the PROPPR trial".
Holcomb JB, Hess JR; PROPPR Study Group. Holcomb JB, et al. Transfusion. 2017 Aug;57(8):2057-2058. doi: 10.1111/trf.14197. Transfusion. 2017. PMID: 28782821 No abstract available.
Misunderstanding the PROPPR trial.
Dzik W. Dzik W. Transfusion. 2017 Aug;57(8):2056. doi: 10.1111/trf.14200. Transfusion. 2017. PMID: 28782822 No abstract available.

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References

1. US Centers for Disease Control and Preventionl. [Accessed December 21, 2014];Injury prevention and control: data and statistics. 2012 http://webappa.cdc.gov/cgi-bin/broker.exe.
1. Rhee P, Joseph B, Pandit V, et al. Increasing trauma deaths in the United States. Ann Surg. 2014;260(1):13–21. - PubMed
1. Tisherman SA, Schmicker RH, Brasel KJ, et al. Detailed description of all deaths in both the Shock and Traumatic Brain Injury Hypertonic Saline Trials of the Resuscitation Outcomes Consortium [published online July 28, 2014] Ann Surg. doi: 10.1097/SLA.0b013e3181df0401. - DOI - PMC - PubMed
1. Holcomb JB, Jenkins D, Rhee P, et al. Damage control resuscitation: directly addressing the early coagulopathy of trauma. J Trauma. 2007;62(2):307–310. - PubMed
1. Holcomb JB, Pati S. Optimal trauma resuscitation with plasma as the primary resuscitative fluid: the surgeon’s perspective. Hematology Am Soc Hematol Educ Program. 2013;2013:656–659. - PubMed

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[1] US Centers for Disease Control and Preventionl. [Accessed December 21, 2014];Injury prevention and control: data and statistics. 2012 http://webappa.cdc.gov/cgi-bin/broker.exe.

[2] US Centers for Disease Control and Preventionl. [Accessed December 21, 2014];Injury prevention and control: data and statistics. 2012 http://webappa.cdc.gov/cgi-bin/broker.exe.

[3] Rhee P, Joseph B, Pandit V, et al. Increasing trauma deaths in the United States. Ann Surg. 2014;260(1):13–21. - PubMed

[4] Rhee P, Joseph B, Pandit V, et al. Increasing trauma deaths in the United States. Ann Surg. 2014;260(1):13–21. - PubMed

[5] Tisherman SA, Schmicker RH, Brasel KJ, et al. Detailed description of all deaths in both the Shock and Traumatic Brain Injury Hypertonic Saline Trials of the Resuscitation Outcomes Consortium [published online July 28, 2014] Ann Surg. doi: 10.1097/SLA.0b013e3181df0401. - DOI - PMC - PubMed

[6] Tisherman SA, Schmicker RH, Brasel KJ, et al. Detailed description of all deaths in both the Shock and Traumatic Brain Injury Hypertonic Saline Trials of the Resuscitation Outcomes Consortium [published online July 28, 2014] Ann Surg. doi: 10.1097/SLA.0b013e3181df0401. - DOI - PMC - PubMed

[7] Holcomb JB, Jenkins D, Rhee P, et al. Damage control resuscitation: directly addressing the early coagulopathy of trauma. J Trauma. 2007;62(2):307–310. - PubMed

[8] Holcomb JB, Jenkins D, Rhee P, et al. Damage control resuscitation: directly addressing the early coagulopathy of trauma. J Trauma. 2007;62(2):307–310. - PubMed

[9] Holcomb JB, Pati S. Optimal trauma resuscitation with plasma as the primary resuscitative fluid: the surgeon’s perspective. Hematology Am Soc Hematol Educ Program. 2013;2013:656–659. - PubMed

[10] Holcomb JB, Pati S. Optimal trauma resuscitation with plasma as the primary resuscitative fluid: the surgeon’s perspective. Hematology Am Soc Hematol Educ Program. 2013;2013:656–659. - PubMed

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Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial

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Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial

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Abstract

Conflict of interest statement

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