The development and feasibility of a remote damage control resuscitation prehospital plasma transfusion protocol for warfarin reversal for patients with traumatic brain injury

Transfusion. 2013 Jan;53 Suppl 1(Suppl 1):59S-64S. doi: 10.1111/trf.12037.


Background: The rapid reversal of warfarin in the setting of traumatic brain injury (TBI) has been associated with improved outcomes. Until now, remote reversal of hypocoagulable states has not been possible in the prehospital environment. This manuscript describes the development and analysis of a prehospital plasma transfusion protocol to reverse warfarin at the earliest possible moment after TBI.

Study design and methods: A retrospective review of all TBI patients receiving plasma transfusion(s) in the prehospital environment for warfarin reversal between February 2009 and September 2010 was conducted. Thawed plasma was carried on every air ambulance flight centered at the main campus.

Results: A total of 2836 flights carried over 2500 units of thawed plasma throughout the study period. During this time, 16 patients received prehospital plasma resuscitation, five of who were on warfarin with a concurrent TBI. The median Injury Severity Score was 17 (8.5-27.5) with a median Glasgow Coma Score of 13 (8-15) and a mortality rate of 40%. A median of 2 (1.5-2.0) units of thawed plasma and 0 (0-0) units of RBCs were transfused en route. The pretransfusion point-of-care international normalized ratio improved from 3.1 (2.3-4.0) to 1.9 (1.3-3.6) upon trauma center admission (serum sample). One hundred percent of the transported, but unused, thawed plasma underwent subsequent transfusion prior to expiration.

Conclusions: Remote prehospital plasma transfusions effectively reverse anticoagulation secondary to warfarin administration in TBI patients. It is feasible to transfuse thawed plasma in the prehospital setting via remote damage control techniques without increasing waste. Prospective studies are needed to determine if this practice can improve outcomes in this population.

MeSH terms

  • Adult
  • Air Ambulances
  • Anticoagulants / adverse effects
  • Anticoagulants / antagonists & inhibitors
  • Blood Coagulation Disorders / blood
  • Blood Coagulation Disorders / etiology
  • Blood Coagulation Disorders / therapy*
  • Brain Injuries / complications
  • Brain Injuries / therapy*
  • Emergency Medical Services / methods*
  • Feasibility Studies
  • Humans
  • Plasma*
  • Resuscitation / methods*
  • Retrospective Studies
  • Warfarin / adverse effects
  • Warfarin / antagonists & inhibitors*


  • Anticoagulants
  • Warfarin