Freeze-Dried Plasma in Emergency Medical Services

The evolution of prehospital care has continually sought to integrate advanced medical interventions traditionally confined to hospital settings. A significant innovation in this domain is the use of freeze-dried plasma (FDP) for emergency transfusions in the field.

How can we use FDP to enhance EMS blood transfusion programs? How is FDP superior to crystalloids in managing major trauma cases, supported by emerging evidence and clinical trials?

According to the American College of Surgeons (ACS), trauma is the leading cause of death for individuals under the age of 45, and hemorrhage is a significant contributor to mortality in these cases.¹ Prehospital resuscitation with blood or plasma holds the potential to change the calculus for resuscitation in the field by EMS, given the fact that the "golden period” is often a decisive factor in patient survival.

When major trauma results in severe blood loss, using crystalloid fluids like saline for initial resuscitation is doing more harm than good. When used to excess traditional crystalloid infusions contribute to exacerbating the trauma triad of death by blowing out clots which then increases bleeding, thinning out the clotting factors making it harder to form clots, and diluting the oxygen-carrying capacity of the blood. The rationale for using blood and plasma lies in their capacity to perform vital functions that crystalloids cannot: carrying oxygen (blood only), ensuring coagulation, and maintaining the osmotic balance.

EMS operates on the frontline of emergency services, often in conditions where resources are limited, and the need for rapid, life-saving interventions is critical. Whole blood administration in the prehospital care arena remains the gold standard for the profession, one that every service should strive to deliver.

Blood transfusion in the field has been a challenging proposition, primarily due to the logistical difficulties in storing and transporting blood products. That does not mean it is an impossible intervention. There are many systems that have successfully implemented blood programs—New Orleans EMS and San Antonio Fire Department to name two.

However, the advent of FDP presents a viable alternative, offering ease of storage, longer shelf life, and rapid reconstitution capabilities for those services that cannot overcome the challenges with instituting a whole blood program.²

What is Plasma?

Plasma is a protein-salt solution that acts as a transportation system for all the other blood components. The red blood cells, white blood cells and the platelets are suspended in this liquid.

Plasma itself is a straw-colored clear liquid that is 90% water. Plasma helps in clotting and fighting infection, and helps maintain blood pressure and immunity. In addition, it helps to maintain minerals (e.g. sodium and potassium) in the body.²

The Role of Freeze-Dried Plasma in EMS

FDP is manufactured by freeze-drying or spray-drying a large batch of plasma.^3–4 It can be stored at room temperature for up to 2 years without losing its hemostatic capabilities. FDP is originally a United States invention, first administered during World War II and then during the Korean War with tremendous effect.

Freeze-dried plasma fell out of favor prior to the Vietnam War because of issues relevant to hepatitis transmission. Israel, Germany, and France picked up the ball and overcame this problem, becoming the leaders, advancing FDP to its current state today.

FDP is a lyophilized product that can be stored at ambient temperatures and quickly reconstituted with sterile water when needed. Its application in military medicine has paved the way for adoption in civilian EMS, especially for managing hemorrhagic shock and coagulopathies in trauma patients. When administering AB-negative FDP, FDP becomes the universal donor, and its compatibility with all blood types simplifies the logistics in urgent scenarios.

Since FDP can be stored at room temperature, implementing an FDP program is almost turnkey for any EMS organization. Its longer shelf life means that the logistics surrounding stock rotation are manageable for every department. In addition, it can be shipped directly to any EMS agency without concern about storage. If it sits in your supply receiving facility for a 3-day weekend it won’t go bad.

Supplementing EMS Blood Transfusion Programs

For EMS systems capable of administering blood products, FDP serves as a critical supplement, particularly in rural or remote areas where transport times to definitive care are extended. The Joint Trauma System Clinical Practice Guideline: Prehospital Blood Transfusion recommends the use of FDP over crystalloids when whole blood is not available.⁵

FDP's ease of use and stability under a range of conditions make it an ideal adjunct, ensuring that patients receive timely care that bridges the gap to hospital-based interventions.6 In large-scale incidents the supply of blood may be stretched thin, or when service demand in certain systems is extraordinarily high and supply is low, FDP is the superior alternative to crystalloids.

In systems that respond to incidents where there may be two or more people suffering from gunshot wounds, and where a single EMS unit is tasked with transporting two critical patients, the utility that comes with having the ability to supplement blood administration with plasma is incalculable. An EMS unit would not have to go out of service to restock blood if they had a reasonable supply of FDP on hand.

In rural or frontier areas or services with low call volume, managing the stocking and re-stocking of FDP would be easier than operating a whole blood program, especially in services that are dependent on volunteer personnel. For any service, regardless of locale, the use of FDP may be an intermediate step for services that want to implement a whole blood program but have multiple hazards they must overcome.

PHTLS recommends taking a measured approach to EMS volume resuscitation, tailoring the administration of fluid to the clinical situation.⁷ In situations in which the patient has uncontrolled hemorrhage, and they are presenting in either Class I or II shock (compensated shock), the recommendation is IV fluids (LR is preferred) at a KVO rate. In situations where the patient has Class III or IV shock, titrate fluid (again LR is preferred) or optimally, the gold standard—add blood products (whole blood or plasma) to maintain a systolic blood pressure of 80 to 90 mm Hg.⁷

In instances where a patient has external hemorrhage that is controlled and there is no suspicion of intrathoracic, intra-abdominal, or intrapelvic injuries and hemorrhage, a more aggressive fluid strategy may be employed.⁷

Advantages Of Crystalloids in Major Trauma

Crystalloids are bad.⁸ Normal saline increases acidosis, which increases mortality (think of the trauma triad of death) and it does not stay in the vascular space. Ringers lactate is better than saline because it does not cause the acidosis that saline causes, and it stays in the vascular space longer, so you don’t have to infuse as much.

Both saline and ringers do not help with blood clotting or with the transport of oxygen. Infusion of too much of either will “blow out” the clots we need to control bleeding, diluting both the oxygen-carrying capacity of the blood as well as the clotting factor necessary to control bleeding.⁹

The administration of crystalloid fluids has been the mainstay in prehospital trauma care due to their availability and ease of use. In contrast, FDP provides not only volume replacement but also essential clotting factors, mitigating the onset of trauma-induced coagulopathy and improving outcomes.¹⁰

FDP has a two-year shelf life, comparable to crystalloids.⁴ In contrast, whole blood has a 25–28 day refrigerated life after which, if it is not administered, it needs to be re-frozen.

Evidence Supporting FDP Use Over Crystalloids

Clinical trials and military experiences have demonstrated the efficacy of FDP in improving survival rates among trauma patients. A landmark study by the U.S. military showed a significant reduction in mortality in patients receiving FDP compared to standard crystalloid therapy.⁹

These findings are corroborated by civilian research, which indicates that FDP administration within the golden hour of trauma significantly enhances patient outcomes. The U.S. military has been using FDP for almost 20 years.⁹

Air medical programs in Australia, the United Kingdom, and Norway use FDP, as well as critical care ground transport teams in Australia.^11–12

Conclusion

The integration of freeze-dried plasma into EMS blood transfusion programs represents a paradigm shift in prehospital trauma care. Its advantages over crystalloids, particularly in managing major trauma and hemorrhage, are supported by a growing body of evidence.

As research continues to evolve, FDP stands out as a superior alternative to crystalloids in those EMS services that do not have the capability or capacity to manage a whole blood program. In services that have existing whole blood programs, the use of FDP to supplement and support their programs is important to their continued readiness. FDP offers a pragmatic and efficacious solution for emergency medical services worldwide.

Daniel Gerard, MS, RN, NRP, is president of the International Association of EMS Chiefs (IAEMSC). 

1. American College of Surgeons. (2022). National Trauma Databank: Annual Report. ACS. 

2. Chapleau W, Burba A, Pons, PM, Page D. (2011). The Paramedic Updated Edition (1st ed.). McGraw-Hill Education 

3. Sunde GA, Vikenes B, Strandenes G, et al. Freeze dried plasma and fresh red blood cells for civilian prehospital hemorrhagic shock resuscitation. J Trauma Acute Care Surg. 2015 Jun;78(6 Suppl 1):S26-30.  

4. Soares JM. (2017, November 27). Saving lives with freeze-dried plasma. Army Medicine. https://www.army.mil/article/197409/saving_lives_with_freeze_dried_plasma 

5. Voller J, Tobin JM, Cap AP, et al. Joint Trauma System Clinical Practice Guideline (JTS CPG): Prehospital Blood Transfusion. 30 October 2020. J Spec Oper Med. 2021 Winter;21(4):11-21.  

6. Dunbar AJ, Richardson DR, Price TH. (2020). The use of freeze-dried plasma in the management of critically ill patients. Transfusion Medicine Reviews, 34(3), 165-171. 

7. PHTLS course manual National Association of Emergency Medical Technicians (US). 10th edition. Burlington, Massachusetts : Jones & Bartlett Learning, [2024] 

8. Cherkas D. Traumatic hemorrhagic shock: advances in fluid management. Emerg Med Pract. 2011 Nov;13(11):1-19 

9. Holcomb JB, Del Junco DJ, Fox EE, et al. (2011). The Prospective, Observational, Multicenter, Major Trauma Transfusion (PROMMTT) Study: Comparative effectiveness of a time-varying treatment with competing risks. JAMA Surgery, 146(2), 127-136. 

10.  Cap AP, Baer DG, Orman, JA (2015). Tranexamic acid for trauma patients: A critical review of the literature. Journal of Trauma and Acute Care Surgery, 79(1), 568-578. 

11. Editorial Team. (2019, December 6). Wiltshire Air Ambulance enhances its life-saving abilities with the addition of plasma. HEMS/SAR. https://www.airmedandrescue.com/latest/news/wiltshire-air-ambulance-enhances-its-life-saving-abilities-addition-plasma. 

12. Newman J, Oliver M, Drobetz H, et al. (2023, April). Freeze-dried plasma administration in trauma – Review of literature and key findings. Agency for Clinical Innovation: The NSW Institute of Trauma and Injury Management Trauma Innovation Committee. Illawarra Shoalhaven LHD. https://aci.health.nsw.gov.au/__data/assets/pdf_file/0007/836521/ACI-Freeze-dried-plasma-administration-in-trauma-evidence-report.pdf