Prehospital Transfusion of Plasma and Red Blood Cells in Trauma Patients

Abstract

Objective. Earlier use of plasma and red blood cells (RBCs) has been associated with improved survival in trauma patients with substantial hemorrhage. We hypothesized that prehospital transfusion (PHT) of thawed plasma and/or RBCs would result in improved patient coagulation status on admission and survival. Methods. Adult trauma patient records were reviewed for patient demographics, shock, coagulopathy, outcomes, and blood product utilization from September 2011 to April 2013. Patients arrived by either ground or two different helicopter companies. All patients transfused with blood products (either pre- or in-hospital) were included in the study. One helicopter system (LifeFlight, LF) had thawed plasma and RBCs while the other air (OA) and ground transport systems used only crystalloid resuscitation. Patients receiving PHT were compared with all other patients meeting entry criteria to the study cohort. All comparisons were adjusted in multilevel regression models. Results. A total of 8,536 adult trauma patients were admitted during the 20-month study period, of which 1,677 met inclusion criteria. They represented the most severely injured patients (ISS = 24 and mortality = 26%). There were 792 patients transported by ground, 716 by LF, and 169 on OA. Of the LF patients, 137 (19%) received prehospital transfusion. There were 942 units (244 RBCs and 698 plasma) placed on LF helicopters, with 1.9% wastage. PHT was associated with improved acid-base status on hospital admission, decreased use of blood products over 24 hours, a reduction in the risk of death in the sickest patients over the first 6 hours after admission, and negligible blood products wastage. In this small single-center pilot study, there were no differences in 24-hour (odds ratio 0.57, p = 0.117) or 30-day mortality (odds ratio 0.71, p = 0.441) between LF and OA. Conclusions. Prehospital plasma and RBC transfusion was associated with improved early outcomes, negligible blood products wastage, but not an overall survival advantage. Similar to the data published from the ongoing war, improved early outcomes are associated with placing blood products prehospital, allowing earlier infusion of life-saving products to critically injured patients.

Équipement des Smur pour la prise en charge préhospitalière du choc hémorragique : peut mieux faire !

“…L'indication peut être posé e par le mé decin du Smur selon l'hé moglobine micromé thode et la tolé rance de l'ané mie aiguë . La transfusion pré hospitaliè re pourrait ré duire les besoins transfusionnels dans les premiè res 24 h, mais la preuve de sa diminution de la mortalité n'a pas é té faite [12]. Quarante-neuf (28 %) Smur ont des concentré s de fibrinogè ne cryopré cipité .…”

“…Les é tudes sont rares concernant l'utilité de la transfusion pré hospitaliè re et l'utilisation des culots globulaires en Smur est exceptionnelle, repré sentant 0,2 à 1 % [11]. La transfusion pré hospitaliè re pourrait ré duire les besoins transfusionnels dans les premiè res 24 h, mais la preuve de la diminution de la mortalité n'a pas é té faite [12].…”

How I treat patients with massive hemorrhage

“…34 We have had plasma and RBCs on our 4 helicopters for the last 2 years, so patients in hemorrhagic shock are transfused with blood products in a balanced fashion before they reach the hospital. 35 Recently, we switched to using liquid plasma as our plasma component before the patient reaches the hospital, because it has a longer shelf life and is similar in vitro hemostatic profile as thawed FFP. 36,37 On arrival at our level 1 trauma center, TEG, hemoglobin, and a venous blood gas are immediately analyzed.…”

Massive transfusion

“…In response to the need for faster treatment, recent studies have demonstrated that getting blood products to patients in the prehospital and pretrauma-center phases of trauma care could be effective in improving early outcomes and reducing incidence of shock and coagulopathy [26][27][28]. The significance of these effects, especially those of prehospital transfusion, remains to be evaluated in larger prospective trials.…”