Washington University Emergency Medicine Journal Club- September 2023
Vignette:
During an EMS rotation, you are riding on a Christian Hospital EMS ambulance, 3017. While driving around North Saint Louis County, the radio tone rings out and
the female computer voice states the following: “4610 and 3017. Gunshot Wound.
Scene is not secure. Shell Gas Station. 2331 Chambers Rd. Cross Street is Lord Dr.
4610 and 3017 respond on North Main.”
As you make your way East on Chambers Rd, you begin to refresh on how to treat
trauma using the MARCH algorithm since it will address the causes of preventable
death from trauma in order of prevalence.
- · Massive External Hemorrhage
- · Airway
- · Respiratory
- · Circulation
- · Hypothermia
After police ensure scene safety, the ambulance proceeds to the patient and you grab
a gear bag while hopping out of the ambulance. Making your way through a crowd of
visibly upset bystanders, you come up to a young, adult male patient lying on the
ground. You immediately notice that his plain white t-shirt has a large blood stain
overlying the right upper quadrant of the abdomen. The patient is moaning,
confused, and keeps saying, “Don’t let me die!” His skin is cool, moist, and slightly
darker than his previously white shirt. After ensuring no massive external
hemorrhage or sucking chest wounds, you notice a small puncture wound in the
RUQ with a small trickle of blood externally. His abdomen is distended and tender,
but his pelvis is stable. His pulses are rapid and thready, and he has some mild
increased work of breathing with clear lung sounds.
Since DePaul is no longer an adult trauma center, your paramedic crew states, “We’ll
be at Barnes in 20 to 30 minutes, so let’s treat while we’re transporting!” In the
ambulance, high-flow oxygen is applied, ECG/SpO2/EtCO2 monitoring is initiated,
two large bore IVs are obtained, and passive warming is started. The first vitals are:
HR – 140, RR – 26, BP 70/50, SpO2 – 92% on O2, EtCO2 – 22 mmHg. The crew gives
the patient a dose of TXA and spikes a liter of 0.9% Normal Saline to treat his
suspected hemorrhagic shock. You begin to wonder if crystalloids are best for this
during your drive to BJH, since you know what he really needs are blood products…
PICO Question
Population: Adult trauma patients with signs of hemorrhagic shock being
transported by EMS
Intervention: Transfusion of whole blood or plasma during prehospital transport
2
Comparison: Standard care, crystalloid infusion
Outcome: Mortality, shock index, organ failure, blood product requirement, need for
massive transfusion
Search Strategy
No formal search was completed. Physicians with expertise in prehospital medicine
selected four high-impact articles for review
Article 1: Moore HB, Moore EE, Chapman MP, et al. Plasma-first resuscitation to
treat haemorrhagic shock during emergency ground transportation in an urban
area: a randomized trial. Lancet. 2018 Jul 28;392(10144):283-291. Answer Key.
Article 2: Braverman MA, Smith A, Pokorny D, et al. Prehospital whole blood
reduces early mortality in patients with hemorrhagic shock. Transfusion. 2021
Jul;61 Suppl 1:S15-S21. Answer Key.
Article 3: Braverman MA, Schauer SG, Ciaraglia A, et al. The impact of prehospital
whole blood on hemorrhaging trauma patients: A multi-center retrospective study. J
Trauma Acute Care Surg. 2023 Aug 1;95(2):191-196. Answer Key.
Article 4: Pusateri AE, Moore EE, Moore HB, et al. Association of Prehospital Plasma
Transfusion With Survival in Trauma Patients With Hemorrhagic Shock When
Transport Times Are Longer Than 20 Minutes: A Post Hoc Analysis of the PAMPer
and COMBAT Clinical Trials. JAMA Surg. 2020 Feb 1;155(2):e195085. Answer Key.
Bottom Line
While prehospital management of non-military hemorrhagic shock in trauma
patients has primarily included resuscitation with IV crystalloid fluids, research in
both the prehospital and ED setting suggest worse outcomes with IV crystalloid
infusion (Chang 2017, Bores 2018). While blood product has become the standard
treatment in the ED for hemorrhagic shock in trauma, most EMS units do not yet
carry blood product. Additionally, prior research (see Journal Club February 2018)
suggests that balanced transfusion strategies may reduce mortality in these patients
(PROMMTT, PROPPR). We therefore sought to evaluate the literature on prehospital
blood and prehospital plasma administration in the management of traumatic shock
in civilian (i.e. nonmilitary) transport.
The COMBAT (Pusateri 2020) and PAMPer (Sperry 2018) trials, both of which were
published in 2018, were both randomized controlled trials that compared the
administration of 2 units of IV plasma to standard care with IV crystalloid among
adult patients with trauma and signs of hemorrhagic shock. The single-center
COMBAT trial found no statistically significant difference in the rates of 28-day
mortality between the plasma group (15%) and the control group (10%) with a
relative risk [RR] of 1.54 (95% CI 0.60 to 3.98), while the larger, multi-center
PAMPer trial found that 30-day mortality was significantly decreased by 9.8% (95%
3
CI -18.6 to -1.0%) with the use of plasma. A subsequent post hoc analysis of
combined data from these two studies also found that 28-day mortality was lower in
the plasma group (20.5%) than in the standard care group (28.6%): HR 0.65, 95% CI
0.47-0.90).
Whole blood is also appealing in the prehospital setting in trauma as it contains all
components of blood, allowing more balanced resuscitation and reducing the risks
of dilutional coagulopathy. While promising results have been seen in the hospital
(Brill 2022), leading to more broad use, two trauma-registry based prehospital
studies were less compelling.
A retrospective study including patients enrolled in the institutional trauma registry
of University Hospital in San Antonio, Texas (Braverman 2021) found no statistically
significant difference in mortality rates from the ED visit through the hospital stay
between those who did and did not receive whole blood during hospital transport.
Following propensity matching, there remained no statistically significant difference
in mortality at any time point. It should be noted, however, that although the
differences did not achieve statistical significance, there was a clinically meaningful
difference in mortality during hospitalization in both the unadjusted cohort (29%
vs. 34.8%; p = 0.25) and the propensity matched groups (25% vs. 13.8%, p = 0.08) in
favor of those who received whole blood. In other words, patients who received
whole blood were 5.8% or 11.2% more likely to survive to hospital discharge, but
the study was underpowered to detect this difference.
Similar findings were observed in a subsequent retrospective study using the
trauma registries of two level 1 trauma centers in Texas (including University
Hospital in San Antonio, Texas) (Braverman 2023). Despite having 1000 more
patients, mortality was still not statistically different between the groups at any time
point; in-hospital mortality was 23.7% among those who did not receive prehospital
blood and 18.7% among those who did. Again, this study was underpowered to
detect a clinically significant difference of 5% in mortality between the groups.
Since journal a club, an abstract of a prospective evaluation of an advanced
resuscitative care (ARC) bundle that included prehospital administration of
tranexamic acid, calcium, and packed RBCs was published. In this study, patients
who received the ARC bundle were enrolledprospectively and compared
retrospectively with historic case controls prior to ARC implementation. Patients
who received ARC had lower 24-hour and in-hospital mortality (risk difference 13%
for both; p = 0.03 and p = 0.04, respectively)