Background: Controversy surrounds the administration of blood products to severely traumatized patients before they arrive in the hospital in order to compensate for early blood loss and/or to correct coagulation disturbances that arise shortly after the traumatic event. A number of terrestrial and air rescue services have begun to provide this kind of treatment.
Methods: This review is based on articles using the PICO framework, published from January 2001 to January 2021, that were retrieved by a selective search, with structured searching strategies and searching bundles in Medline (OVIDSP), the Cochrane Central Register of Controlled Trials (CENTRAL), and Epistemonikos. A demand analysis was carried out on the basis of data from the trauma registry of the German Society of Trauma Surgery (TR-DGU) and practical experience from program development and implementation was provided by the Bundeswehr Hospital Ulm.
Results: The currently available evidence on the pre-hospital administration of blood products in the early treatment of severely injured patients is based largely on retrospective, single-center case series. Two randomized controlled trials (RCTs) concerning the early use of fresh frozen plasma concentrates have yielded partly conflicting results. Three further RCTs on the use of lyophilized plasma (lyplas), lyplas plus erythrocyte concentrate, or whole blood likewise revealed non-uniform effects on short-term and intermediate-term mortality. Our demand analysis based on data from the TR-DGU showed that 300 to 1800 patients per year in Germany could benefit from the pre-hospital administration of blood products. This might be indicated in patients who have systolic hypotension (<100 mmHg) in combination with a suspected or confirmed hemorrhage, as well as pathological shock parameters in the point-of-care diagnostic testing performed on the scene (serum base excess ≤ -2.5 mmol/L and/or serum lactate concentration >4 mmol/L).
Conclusion: The studies that have been published to date yield no clear evidence either for or against the early pre-hospital administration of blood products. Any treatment of this kind should be accompanied by scientific evaluation.
Review Article
Uncontrolled bleeding combined with impaired coagulation--designated as trauma-induced coagulopathy (TIC)--is still the most common preventable cause of death after severe multiple trauma (
In Germany, the pre-hospital administration of blood products is currently a matter of debate; some ground- and air-based rescue systems have started to provide them. In this review, we summarize the current scientific evidence and the current state of affairs in Germany and presents a needs assessment based on data from the Trauma Registry of the German Trauma Society (TR-DGU).
A selective review of the literature from January 2001 to January 2021 in PICO format was carried out with the aid of structured search strategies/search bundles in Medline (OVIDSP), the Cochrane Central Register of Controlled Trials (CENTRAL), and Epistemonikos (
The pre-hospital administration of blood products
The pre-hospital administration of blood products is feasible and is currently implemented in many countries with methods that vary from one location to another (
Blood plasma products
Two pragmatic randomized controlled trials in the United States, the Prehospital Air Medical Plasma (PAMPer) trial (
The pre-hospital use of freeze-dried, lyophilized plasma has logistical advantages, and retrospective civilian data document its clinical utility, beneficial effects on clotting function (e8) and low total transfusion requirement when given in a bolus together with pre-hospital erythrocyte concentrates (e9). In the randomized and controlled PREHO-PLYO trial, conducted in France, patients at risk for hemorrhagic shock and coagulopathy, stratified by clinical kinetic criteria, systolic blood pressure (SBP) < 70 mmHg and/or shock index (SI) > 1.1, were treated with the pre-hospital administration of either lyophilized plasma (lyPlas) or saline solution (0.9% NaCl) (
The pre-hospital administration of erythrocyte concentrates
The findings of single-center observational studies and retrospective data analyses suggest that the pre-hospital administration of EC increases survival rates (e10), especially when given in the early pre-hospital care phase (
Inclusion criteria Included patients (n) Primary endpoint Transport Trial medication Time from accident to hospital treatment (min) Blunt trauma (%) Prehospital EC administration Traumatic brain injury (%) Crystalloids (mL) Injury severity Tranexamic acid (%) Treatment outcome: 24-hour mortality (%). 28/30-day mortality (%) COMBAT (
The combined administration of erythrocyte and fresh plasma concentrates
In PAMPer, 26% of the patients in the plasma group and 42% in the standard therapy group also received EC in the pre-hospital phase (
* crystalloid solutions only
* EC only
* plasma only
* EC and plasma.
The patients who received EC and plasma had the highest survival at 30 days (hazard ratio [HR] 0.38; 95% CI: [0.26; 0.55], p < 0.001), followed by the plasma group (HR 0.57; 95% CI: [0.36; 0.91], p = 0.017) and the EC group (HR 0.68; 95% CI: [0.49; 0.95], p = 0.025) (
In a recently published multicenter phase 3 trial called RePHILL, adult hypotensive trauma patients in hemorrhagic shock were randomized to receive either up to two units of EC and lyPlas or up to one liter of NaCl 0.9% (Table 1) (
The pre-hospital administration of whole blood
The pre-hospital administration of whole blood was studied in 214 matched trauma patients in shock with registry data from a single center (
Critical assessment of the current state of the evidence
The evidence from the randomized trials and retrospective analyses performed to date on the pre-hospital administration of blood products to trauma patients remains inconsistent. A meta-analysis of the randomized trials summarized in Table 1 with respect to 28/30-day mortality yields a relative risk (RR) of 0.88 (95% CI: [0.71; 1.09], p = 0.24): this finding favors the intervention but is statistically insignificant. Persistent problems in the interpretation of study findings include the limited quality of the data, with marked heterogeneity of study design and interventions, as well as the inclusion of secondary analyses with their known drawbacks, e.g., with respect to data quality, confounding factors, multiple testing, and bias of several kinds (publication, selection, and interpretation bias).
Category Group 1: SBP < 90 mmHg Group 2: SBP < 90 mmHg and/or HR > 120/min Group 3: SBP < 90 mmHg and HR > 108/min or SBP < 70 mmHg Group 4: shock index ≥ 1 Life-threatening injury MAIS ≥ 3 (n = 17 771; 80%) 907 (6.0%) 1781 (11.4%) 551 (3.6%) 1472 (10.1%) ISS ≥ 16 (n = 11 009; 50%) 764 (8.0%) 1390 (14.5%) 488 (5.1%) 1152 (13.1%) Polytrauma (Berlin definition) (n = 2 244; 10%) 477 (25.8%) 727 (36.9%) 332 (17.4%) 578 (34.6%) * Analysis based on data from the Trauma Registry of the German Trauma Society (TR-DGU; basic dataset for 2021 including primary trauma patients treated in certified German trauma centers, n = 22 106; missing data approx. 15%) (e22). In the TR-DGU, the severity of each individual injury is graded on the Abbreviated Injury Scale (AIS) from 1 (mild) to 6 (maximal). From this, overall severity scores such as the maximum AIS severity score (MAIS), the Injury Severity Score (ISS), and the New ISS (NISS) can be calculated (e22). As for the definition of polytrauma, patients can be assigned to any of the following categories in the TR-DGU: 1) life-threatening injury (80%), i.e. MAIS ≥ 3 (this category has been defined as „serious injury” by the European Union and is used in reports of traffic accidents) (e22); 2 ) ISS ≥ 16 (50%; this category corresponds to the classic definition of polytrauma) (e23); 3) Berlin definition (10%), according to which at least two body regions must be injured to a relevant extent, and at least one physiological impairment must be present (e24). In accordance with the varying definitions of hemodynamic instability, patients were classified in four groups (
Needs assessment based on data from the TR-DGU and the Blood in Emergency Medical Services Registry
The potential need for pre-hospital blood products in Germany, was estimated with the aid of the TR-DGU baseline dataset from certified German trauma centers for the year 2021, with 22 106 primarily documented patients (e22). Table 2 shows the estimated need on the assumption of a variety of definitions for hemodynamic instability, shock, and injury severity/polytrauma, based on the data available from the TR-DGU for the pre-hospital and early in-hospital care phases (e22). The annual need is estimated to arise in approximately 300 severely injured persons, on the criterion of SBP < 90 mmHg and heart rate (HR) > 108/min or SBP < 70 mmHg and the Berlin Definition of polytrauma, and in nearly 1800 persons on the criterion of SBP < 90 mmHg and/or HR > 120/min and a life-threatening injury (Maximum Abbreviated Injury Scale [MAIS] ≥ 3). The broad range in estimates is mainly due to the lack of a uniformly accepted definition of hemodynamic instability (
Half of all pre-hospital transfusions to date are for bleeding of nontraumatic origin, primarily gastrointestinal and peripartum bleeding (e14, e27, e28). Patients in this category are not included in the TRDGU; nor are trauma patients who die at the scene of the accident or before arrival in the hospital. The total annual need for pre-hospital blood product administration is thus, presumably, higher than the estimates above. There is, however, a worsening shortage of blood products at present, accompanied by unresolved cost issues. The in-hospital supply of emergency reserves (blood group 0 rhesus-negative) must retain absolute priority unless and until there is clear evidence for the benefit of pre-hospital administration. In principle, storage should be organized so that blood products issued to emergency medical services can be returned to in-hospital use in timely fashion, well before their expiration date, without any interruption of the refrigeration chain. With the aim of improving the state of the evidence, work has recently begun on the establishment of a Blood in Emergency Medical Services registry („Blut im Notarzt dienst”-Register, BiNAR) under the aegis of the Federal Association of Emergency Physicians in Germany (Bundesvereinigung der Arbeitsgemeinschaften Notärzte Deutschlands, BAND), with a core team of representatives of the ADAC air rescue service, the German Federal Office of Civil Protection and Disaster Assistance/Air Rescue (Bundesamt für Bevölkerungsschutz und Katastrophenhilfe/Luftrettung), the German Air Rescue Service (Deutsche Rettungsflugwacht, DRF), and the Air Rescue Foundation (Stiftung Luftrettung), and independent experts (
Experiences in program development and implementation
The PREDICT study (
In order to keep the expiration of unused ECs to a minimum, the blood depot and the rescue helicopter agreed on a way to return ECs promptly to the hospital if they are not used in the field, while maintaining an unbroken refrigeration chain. This is important because, despite the frequent provision of trauma care by the rescue helicopter, pre-hospital transfusion is only needed approximately eight times per year on average. It follows that there is a need for an evidence-based method of using patient-specific parameters, obtainable in the preclinical phase, to determine which patients would benefit from early treatment of this kind. It was concluded from the PREDICT study that the simultaneous occurrence of systolic blood pressure under 100 mm Hg at, assumed or verified hemorrhage, a serum base excess (BE) under -2.5 mmol/L, and a serum lactate concentration above 4 mmol/L, all measured at the point of care (i.e., the scene of the accident), may be an indication for the pre-hospital administration of blood products (
There has not been any randomized, controlled trial to date whose results clearly support the early pre-hospital administration of blood products, although secondary analyses suggest that selected patients may well stand to benefit from it.
The care of severely injured patients now centers on guideline-based treatment; the pre-hospital administration of blood products may be possible as an adjunct and can be taken into consideration if the logistics permit, and as long as it does not cause any delay in the transport of the patient to the destination hospital (
Any program for the pre-hospital administration of blood products must be implemented with observance of the applicable transfusion regulations, including safety aspects and quality assurance.
Maintaining an adequate supply of blood products for emergency use in the hospital (blood group 0 Rhesus-negative) still has absolute priority unless and until there is a better evidence base for their pre-hospital use.
Any pre-hospital administration of blood products should be scientifically monitored; emergency services that stock blood products are encouraged to participate in the BiNAR registry.
The authors would like to thank Prof. Dr. Rolf Lefering (IFOM Cologne-Merheim) for help in analyzing data from the TR-DGU.
Artificial intelligence was not used either for manuscript preparation or for data analysis.
MM has received lecture honoraria, payment for participation in expert and advisory panels, and financial support for scientific meeting participation from the following firms: Astra Zeneca, Baxter, Bayer, Biotest, CSL Behring, IL-Werfen/TEM-International, LFB Biomedicaments France, Octapharma, and Portola.
HL has received lecture honoraria and reimbursement of travel expenses and scientific meeting participation fees from the following firms: Bayer Vital, DRK-BlutspendedienstWest, CSL Behring, Ferring, Mitsubishi Pharma, NovoNordisk, and Werfen.
BH has received lecture honoraria and reimbursement of travel expenses from Karl Storz, Weinmann Emergency, and CSL Behring. He is the chairman of the Professional Association of Emergency Physicians in Bavaria (Arbeitsgemeinschaft in Bayern tätiger Notärztinnen und Notärzte, agbn).
Manuscript received on 29 March 2023, revised version accepted on 13 July 2023.
Supplementary material eReferences:
by Marc Maegele*, Heiko Lier*, and Björn Hossfeld
Dtsch Arztebl Int 2023; 120: 670-6. DOI: 10.3238/arztebl.m2023.0176
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The submission deadline is 5 October 2024. Only one answer is possible per question.
Please select the answer that is most appropriate.
Question 1
What does the trial acronym PAMPer stand for?
a) pre-hospital air medical plasma
b) pre-hospital ambulance medical plasma
c) plasma ambulance medical program
d) pre-hospital and accident medical plasma
e) plasma assisted medical program
Question 2
How many units of blood plasma per patient were administered in the PAMPer and COMBAT trials?
a) 1
b) 2
c) 3
d) 4
e) 5
Question 3
The French PREHO-PLYO trial was conducted to study the pre-hospital administration of lyophilized plasma. Which of the following findings is described in the text?
a) an improved INR (international normalized ratio) value on admission to the trauma emergency room (ER)
b) an improved fibrinogen level on trauma ER admission
c) lower 28-day mortality
d) marked hypertension on trauma ER admission
e) higher mortality at 6 hours, 24 hours, and 28 days
Question 4
According to a secondary analysis in the PAMPer trial, administration of which of the following was associated with the highest survival rate at 30 days?
a) only plasma
b) erythrocyte concentrates and plasma
c) only erythrocyte concentrates
d) only crystalloid
e) only tranexamic acid
Question 5
This review contains A flowchart for the pre-hospital administration of blood products under trial conditions on the Christoph 22 rescue transport helicopter. What was the first product given after blood drawing?
a) 2 0neg erythrocyte concentrates
b) 2 g fibrinogen concentrate
c) balanced electrolyte solution
d) 1 g tranexamic acid and 10 mL calcium gluconate
e) 2 ABpos erythrocyte concentrates
Question 6
What does ISS stand for in this article?
a) Ischemia Severity Score
b) Instant Solution of Serum
c) Injury Severity Score
d) International Severity Score
e) Instant Serum Safety
Question 7
Which of the following were inclusion criteria in the PAMPer and PPOWER trials?
a) SBP < 100 mmHg and HR > 102/min
b) DBP < 70 mmHg and HR > 95/min
c) SBP > 100 mmHg and HR < 90/min
d) DBP < 90 mmHg and HR > 95/min
e) SBP ≤ 90 mmHg and HR ≥ 108/min
Question 8
In the PPOWER trial, what was the result of the comparison of 86 persons at risk for massive bleeding who were given LT0BW compared to standard treatment?
a) no difference in mortality at 28 days
b) lower mortality at 28 days
c) higher mortality at 6 months
d) lower morbidity at 28 days
e) higher morbidity at 28 days
Question 9
What does lyPlas stand for in this article?
a) lysed plasma
b) pasteurized plasma
c) lymphocyte-rich plasma
d) fresh frozen plasma
e) microfiltered plasma
Question 10
What additional criteria were set in the PREDICT trial for a possible indication for the pre-hospital administration of blood products in patients with systolic blood pressure <100 mm Hg and assumed or known hemorrhage?
a) oxygen partial pressure > 108 mmHg and serum lactate < 4 mmol/L
b) CO
c) serum base excess < -2.5 mmol/L and/or serum lactate > 4 mmol/L
d) anion gap < 8 mmol/L and serum lactate > 4 mmol/L
e) current bicarbonate > 22 mmol/L and serum lactate < 4 mmol/L
By Marc Maegele, Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Cologne: Prof. Dr. med. Marc Maegele; Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Campus Cologne-Merheim, Cologne: Prof. Dr. med. Marc Maegele; Heiko Lier, Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne: Dr. med. Heiko Lier; Joint first authors and Björn Hossfeld, Department of Anaesthesiology and Intensive Care Medicine, Armed Forces Hospital Ulm, Ulm: PD Dr. med. Björn Hossfeld; Rescue transport helicopter (RTH) „Christoph 22” Ulm, ADAC-Air Rescue, Ulm: PD Dr. med. Björn Hossfeld; Joint first authors
Translated from the original German by Ethan Taub, M.D.
Corresponding author Prof. Dr. med. Marc Maegele Klinik für Orthopädie, Unfallchirurgie und Sporttraumatologie Kliniken der Stadt Köln-Merheim Institut für Forschung in der Operativen Medizin (IFOM) Universität Witten/Herdecke Ostmerheimer Str. 200, D-51109 Cologne, Germany Marc.Maegele@t-online.de. Joint first authors.