A 26-year-old woman is brought to the emergency department after a motor vehicle collision. She sustained multiple long-bone fractures and undergoes emergent surgery. Several hours later, she develops diffuse oozing from intravenous catheter sites and surgical incisions. Physical examination reveals extensive ecchymoses. Laboratory studies show the following:
Hemoglobin: 9.8 g/dL
Platelet count: 95,000/mm³
Prothrombin time (PT): 18 seconds
Activated partial thromboplastin time (aPTT): 44 seconds
Fibrinogen: 70 mg/dL (normal: 200–400 mg/dL)
D-dimer: Elevated
Which of the following blood products is most appropriate to administer at this time?
The correct answer is:
E) Cryoprecipitate
Cryoprecipitate is a concentrated blood product that contains fibrinogen, factor VIII, factor XIII, von Willebrand factor, and fibronectin. It is indicated for patients with significant hypofibrinogenemia, particularly when associated with active bleeding. This patient has disseminated intravascular coagulation (DIC) following major trauma, as evidenced by diffuse bleeding, elevated D-dimer, prolonged coagulation studies, and a markedly decreased fibrinogen level. Cryoprecipitate is the most appropriate therapy to rapidly replenish fibrinogen stores and improve hemostasis.
Answer choice A: Fresh frozen plasma, is incorrect. Fresh frozen plasma contains all clotting factors and can help correct prolonged PT and aPTT. However, this patient's most critical abnormality is severe hypofibrinogenemia. Cryoprecipitate provides a much higher concentration of fibrinogen and is preferred when fibrinogen levels are markedly reduced.
Answer choice B: Packed red blood cells, is incorrect. Packed red blood cells are used to increase oxygen-carrying capacity in patients with significant anemia or hemorrhage. Although this patient may ultimately require red blood cell transfusion, the primary hemostatic abnormality requiring correction is severe fibrinogen deficiency.
Answer choice C: Platelets, is incorrect. Platelet transfusion is generally indicated when thrombocytopenia is severe or contributing to active bleeding. Although the platelet count is somewhat reduced, the fibrinogen level is critically low and is the most important abnormality to address.
Answer choice D: Prothrombin complex concentrate, is incorrect. Prothrombin complex concentrate is primarily used for rapid reversal of warfarin-associated coagulopathy. It does not provide adequate fibrinogen replacement and is not the treatment of choice in this setting.
Key Learning Point
Cryoprecipitate is indicated for patients with active bleeding and severe hypofibrinogenemia. It contains concentrated fibrinogen, factor VIII, factor XIII, and von Willebrand factor. Common indications include disseminated intravascular coagulation, massive transfusion protocols, liver disease with low fibrinogen levels, and congenital or acquired fibrinogen deficiencies.
