Traumatic brain injury and resuscitation with blood products: what should we do?

As the study by Dr Peiniger and colleagues [1] correctly indicates, many retrospective studies have demonstrated a survival benefit from transfusion strategies using an early and more balanced ratio between fresh frozen plasma (FFP) and red blood cell (RBC) transfusions in patients with acute traumatic coagulopathy requiring massive transfusion within the first 24 hours of hospitalization. However, this topic has never been explored in depth in patients with concomitant severe traumatic brain injury (TBI). Previous studies have included these patients, but they were not the focus of investigation [2]. While the study by Dr Peiniger and colleagues is retrospective and certainly not a substitute for a well-designed prospective trial, the authors nonetheless should be commended for addressing this issue with their current work. Currently, the optimum fluid resuscitation paradigm for patients with both severe TBI and other injuries requiring significant volume resuscitation is not clear. The Brain Trauma Foundation guidelines are silent on the issue of FFP:RBC ratios. Resuscitation and avoidance of hypotension is a primary goal, but the actual fluid within which to accomplish an optimal resuscitation is unknown. Bulger and colleagues [3] recently demonstrated that among injured patients with hypovolemic shock, initial resuscitation fluid treatment with either hypertonic saline or hypertonic saline/dextran compared with normal saline did not result in superior 28-day survival. The novelty of this current study is its focus on a high FFP:RBC ratio in resuscitation of profoundly hypovolemic TBI patients.As the authors point out in their introduction, a major issue with these patients is coagulopathy at initial presentation. Coagulopathy in severe TBI patients can lead to profound hematoma expansion resulting in significant morbidity and mortality. A current active area of TBI research is the study of the mechanisms by which cerebral contusions expand. Additionally, TBI pat