A specific example of the combination of these three strategies – suitable for a definitive-treatment center and applied to patients who are identified as at high risk for massive hemorrhage – is shown in Figure Figure11.Platelet concentratesAt the University of Maryland program, <3% of patients with an Injury Severity Score >15 had an admission platelet count <100,000/��l [79]. Thrombocytopenia will generally not develop until at least one blood volume of resuscitation has occurred. There is currently no high-quality evidence to support the use of up-front platelet transfusions. These platelet transfusions do not reverse antiplatelet agents such as clopidogrel and there is no evidence to support use of platelet transfusions to improve outcomes in patients who have recently taken antiplatelet agents [80]. Retrospective studies in both trauma patients and nontrauma patients with intracranial hemorrhage have found no benefit from platelet transfusions given to patients who are taking antiplatelet agents [81-83].FibrinogenBecause a decline in fibrinogen concentration is seen in hyperfibrinolysis, consumption coagulopathy, disseminated intravascular coagulation, and hemodilution, and because a decline in fibrinogen is observed in massively injured patients, specific attention to fibrinogen may be of merit in transfusion support of critical bleeding [45]. Fresh frozen plasma and thawed plasma contain physiologic levels of fibrinogen. Higher concentrations of fibrinogen are found in cryoprecipitate and in fibrinogen concentrates. Current evidence does not support the superiority of one source of fibrinogen over another [15].Prothrombin complex concentratesWhether or not infusion of prothrombin complex concentrates used either as a substitute for plasma or as a supplement to plasma is safe or improves outcomes beyond that which would be observed without their use has not been adequately studied (a lack of data).Transfusion and trauma care in both small, rural and large, urban healthcare facilitiesCanadians residing in rural and remote locations have been shown to be at increased risk of sustaining severe injuries, and to have decreased access to definitive trauma care once injuries occur [58]. Despite the greater challenges to care, smaller hospitals not specializing in trauma can apply early treatments of proven value such as tranexamic acid. Because no single approach to transfusion support of trauma patients is of proven superiority, there is no requirement that specific practices regarding blood products be imposed as an absolute standard of care.