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Prehospital Blood Product and Crystalloid Resuscitation in the Severely Injured Patient: A Secondary Analysis of the Prehospital Air Medical Plasma Trial

Department of Emergency Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA. Division of General Surgery and Trauma, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA. Department of Surgery, University of Tennessee Health Science Center, Knoxville, TN. Department of Surgery, Vanderbilt University Medical Center, Nashville, TN. Department of Surgery, University of Louisville, Louisville, KY. MetroHealth Medical Center/Case Western Reserve University, Cleveland, OH. University of Pittsburgh Medical Center, Altoona Hospital, Altoona, PA. John Peter Smith Health Network, Fort Worth, TX. Department of Surgery, University of Texas Southwestern/ Parkland Memorial Hospital, Dallas, TX.

Annals of surgery. 2019
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Abstract
MINI: Hemorrhage is the primary cause of preventable trauma death. Secondary analyses of scene patients from the PAMPer trial demonstrated that prehospital packed red blood cell and plasma had the greatest reduction in 30-day mortality compared with crystalloid-only resuscitation. Patients with hemorrhagic shock should receive prehospital blood products when available, preferably packed red blood cell and plasma. OBJECTIVE The aim of this study was to determine whether prehospital blood products reduce 30-day mortality in patients at risk for hemorrhagic shock compared with crystalloid only resuscitation. SUMMARY OF BACKGROUND DATA Hemorrhage is the primary cause of preventable death after injury. Large volume crystalloid resuscitation can be deleterious. The benefits of prehospital packed red blood cells (PRBCs), plasma, or transfusion of both products among trauma patients is unknown compared with crystalloid. METHODS Secondary analysis of the multicenter PAMPer trial was performed on hypotensive injured patients from the scene. The trial randomized 27 helicopter bases to prehospital plasma or standard resuscitation. Standard resuscitation at the sites was equally divided between crystalloid and crystalloid + PRBC. This led to 4 prehospital resuscitation groups: crystalloid only; PRBC; plasma; and PRBC+plasma. Cox regression determined the association between resuscitation groups and risk-adjusted 30-day mortality. The dose effect of resuscitation fluids was also explored. RESULTS Four hundred seven patients were included. PRBC+plasma had the greatest benefit [hazard ratio (HR) 0.38; 95% confidence interval (95% CI) 0.26-0.55, P < 0.001], followed by plasma (HR 0.57; 95% CI 0.36-0.91, P = 0.017) and PRBC (HR 0.68; 95% CI 0.49-0.95, P = 0.025) versus crystalloid only. Mortality was lower per-unit of PRBC (HR 0.69; 95% CI 0.52-0.92, p = 0.009) and plasma (HR 0.68; 95% CI 0.54-0.88, P = 0.003). Crystalloid volume was associated with increased mortality among patients receiving blood products (HR 1.65; 95% CI 1.17-2.32, P = 0.004). CONCLUSION Patients receiving prehospital PRBC+plasma had the greatest mortality benefit. Crystalloid only had the worst survival. Patients with hemorrhagic shock should receive prehospital blood products when available, preferably PRBC+plasma. Prehospital whole blood may be ideal in this population.
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Language : eng
Credits : Bibliographic data from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine