Pretrauma center red blood cell transfusion is associated with reduced mortality and coagulopathy in severely injured patients with blunt trauma

RePHILL: protocol for a randomised controlled trial of pre-hospital blood product resuscitation for trauma

OBJECTIVES

To describe the 'Resuscitation with Pre-HospItaL bLood products' trial (RePHILL) - a multi-centre randomised controlled trial of pre-hospital blood product (PHBP) administration vs standard care for traumatic haemorrhage.

BACKGROUND

PHBP are increasingly used for pre-hospital trauma resuscitation despite a lack of robust evidence demonstrating superiority over crystalloids. Provision of PHBP carries additional logistical and regulatory implications, and requires a sustainable supply of universal blood components.

METHODS

RePHILL is a multi-centre, two-arm, parallel group, open-label, phase III randomised controlled trial currently underway in the UK. Patients attended by a pre-hospital emergency medical team, with traumatic injury and hypotension (systolic blood pressure <90 mmHg or absent radial pulse) believed to be due to traumatic haemorrhage are eligible. Exclusion criteria include age <16 years, blood product receipt on scene prior to randomisation, Advanced Medical Directive forbidding blood product administration, pregnancy, isolated head injury and prisoners. A total of 490 patients will be recruited in a 1 : 1 ratio to receive either the intervention (up to two units of red blood cells and two units of lyophilised plasma) or the control (up to four boluses of 250 mL 0.9% saline). The primary outcome measure is a composite of failure to achieve lactate clearance of ≥20%/h over the first 2 hours after randomisation and all-cause mortality between recruitment and discharge from the primary receiving facility to non-acute care. Secondary outcomes include pre-hospital time, coagulation indices, in-hospital transfusion requirements and morbidity.

RESULTS

Pilot study recruitment began in December 2016. Approval to proceed to the main trial was received in June 2017. Recruitment is expected to continue until 2020.

CONCLUSIONS

RePHILL will provide high-quality evidence regarding the efficacy and safety of PHBP resuscitation for trauma.

Pre-hospital transfusion of red blood cells in civilian trauma patients

INTRODUCTION

The current management of severely injured patients includes damage control resuscitation strategies that minimise the use of crystalloids and emphasise earlier transfusion of red blood cells (RBC) to prevent coagulopathy. In 2012, London's air ambulance (LAA) became the first UK civilian pre-hospital service to routinely carry RBC to the trauma scene.

OBJECTIVE

To investigate the effect of pre-hospital RBC transfusion (phRTx) on overall blood product consumption.

METHODS

A retrospective trauma database study compares before implementation with after implementation of phRTx in exsanguinating trauma patients transported directly to one major trauma centre. Pre-hospital deaths were excluded. Univariate and multivariate Poisson regression analyses on data subject to multiple imputation were conducted.

RESULTS

We included 137 and 128 patients in the before and after the implementation of phRTx groups, respectively. LAA transfused 304 RBC units (median 2, inter quartile range 1-3). We found a significant reduction in total RBC usage and reduced early use of platelets and fresh-frozen plasma (FFP) after the implementation of phRTx in both univariate (P < 0·001) and multivariate analyses (P < 0·001). No immediate adverse transfusion reactions were identified.

CONCLUSION

Pre-hospital trauma transfusion practice is feasible and associated with overall reduced RBC, platelets and FFP consumption.

Prehospital Assessment of Trauma

The organization of prehospital care for trauma patients began in the military arena. At the urging of multiple stakeholders and providers, these lessons were applied to the civilian setting and emergency medical services were created across the nation. Advances have taken place in the triage, transport, and management of severely injured patients. Many issues remain in the care of trauma patients in the prehospital environment. Collaboration between stakeholders and providers, regionalization of trauma care, and protocol-driven care may be solutions to some of these issues. Further research is necessary to dictate standard of care in this early phase after injury.

Volumetric control of whole blood collection in austere environments

INTRODUCTION

Fresh whole blood transfusions are a powerful tool in prehospital care; however, the lack of equipment such as a scale in field situations frequently leads to collections being under- or overfilled, leading to complications for both patient and physician. This study describes two methods for simple, rapid control of collection bag volume: (1) a length of material to constrict the bag, and (2) folding/clamping the bag.

METHOD

Whole blood collection bags were allowed to fill with saline via gravity. Paracord, zip-tie, beaded cable tie, or tourniquet was placed around the bag at circumferences of 6 to 8.75 inches. A hemostat was used to clamp folds of 1 to 1.5 inches. Several units were drawn during training exercises of the 75th Ranger Regiment with volume controlled by three methods: vision/touch estimation, constriction by paracord, and clamping with hemostat.

RESULTS

Method validation in the Terumo 450-mL bag indicated that paracord, zip-tie, and beaded cable tie lengths of 6.5 inches or clamping 1.25 inches with a hemostat provided accurate filling. The volume variance was significantly lower when using the beaded cable tie. Saline filling time was approximately 2 minutes. With the Fenwal 450-mL bag, the beaded cable tie gave best results; even if incorrectly placed by one/two beads, the volume was still within limits. In training exercises, the use of the cord/clamp greatly reduced the variability; more bags were within limits.

CONCLUSIONS

Both constricting and clamping allow for speed and consistency in blood collection. The use of common cord is appealing, but knot tying induces inevitable variability; a zip/cable tie is easier. Clamping was quicker but susceptible to high variance and bag rupturing. With proper methodological training, appropriate volumes can be obtained in any environment with minimal tools.

LEVEL OF EVIDENCE

Therapeutic/care management study, level IV.

Multicenter observational prehospital resuscitation on helicopter study

BACKGROUND

Earlier use of in-hospital plasma, platelets, and red blood cells (RBCs) has improved survival in trauma patients with severe hemorrhage. Retrospective studies have associated improved early survival with prehospital blood product transfusion (PHT). We hypothesized that PHT of plasma and/or RBCs would result in improved survival after injury in patients transported by helicopter.

METHODS

Adult trauma patients transported by helicopter from the scene to nine Level 1 trauma centers were prospectively observed from January to November 2015. Five helicopter systems had plasma and/or RBCs, whereas the other four helicopter systems used only crystalloid resuscitation. All patients meeting predetermined high-risk criteria were analyzed. Patients receiving PHT were compared with patients not receiving PHT. Our primary analysis compared mortality at 3 hours, 24 hours, and 30 days, using logistic regression to adjust for confounders and site heterogeneity to model patients who were matched on propensity scores.

RESULTS

Twenty-five thousand one hundred eighteen trauma patients were admitted, 2,341 (9%) were transported by helicopter, of which 1,058 (45%) met the highest-risk criteria. Five hundred eighty-five of 1,058 patients were flown on helicopters carrying blood products. In the systems with blood available, prehospital median systolic blood pressure (125 vs 128) and Glasgow Coma Scale (7 vs 14) was significantly lower, whereas median Injury Severity Score was significantly higher (21 vs 14). Unadjusted mortality was significantly higher in the systems with blood products available, at 3 hours (8.4% vs 3.6%), 24 hours (12.6% vs 8.9%), and 30 days (19.3% vs 13.3%). Twenty-four percent of eligible patients received a PHT. A median of 1 unit of RBCs and plasma were transfused prehospital. Of patients receiving PHT, 24% received only plasma, 7% received only RBCs, and 69% received both. In the propensity score matching analysis (n = 109), PHT was not significantly associated with mortality at any time point, although only 10% of the high-risk sample were able to be matched.

CONCLUSION

Because of the unexpected imbalance in systolic blood pressure, Glasgow Coma Scale, and Injury Severity Score between systems with and without blood products on helicopters, matching was limited, and the results of this study are inconclusive. With few units transfused to each patient and small outcome differences between groups, it is likely large, multicenter, randomized studies will be required to detect survival differences in this important population.

LEVEL OF EVIDENCE

Level II.

Blood transfusion: In the air tonight?

BACKGROUND

The use of prehospital blood transfusion (PBT) in air medical transport has become more widespread. However, the effect of PBT remains unknown. The aim of this study was to examine the impact of PBT on 24-hour and overall in-hospital mortality.

METHODS

This is a retrospective cohort study of all trauma patients carried by air medical transport from the scene to a Level I trauma center from 2007 to 2013. We excluded patients who died on the helipad or in the emergency department. Primary outcomes measured were 24-hour and overall in-hospital mortality. Multivariable logistic regressions using all available patient data or the propensity score (for receiving PBT)-matched patient data were performed to study the effect of PBT on these outcomes.

RESULTS

Of the 5,581 patients included in the study, 231 (4%) received PBT. Multivariable regression analyses did not show evidence of PBT effect on 24-hour in-hospital mortality (odds ratio [OR], 1.22; 95% confidence interval [CI], 0.61-2.44) and on overall in-hospital mortality (OR, 1.20; 95% CI, 0.55-1.79). In addition, using 1:1 propensity score-matched data, the analysis did not show evidence of PBT effect on 24-hour in-hospital mortality (OR, 1.04; 95% CI, 0.54-1.98) and on overall in-hospital mortality (OR, 1.05; 95% CI, 0.56-1.96). Factors associated with increased 24-hour mortality were advanced age, penetrating injury, increased blood transfusion requirement in the first 24 hours, and decreased Glasgow Coma Scale (GCS) score (p < 0.05). These factors were also associated with overall mortality, in addition to increased Injury Severity Score (ISS) (p < 0.05).

CONCLUSION

This is the largest study to date of trauma patients who received PBT and were transported from the scene by air medical transport. Our results show no effect of PBT on 24-hour and overall in-hospital mortality. Previous studies also suggest no benefit of PBT, which is counterintuitive to damage-control resuscitation. Prospective data on PBT are needed to assess risk, cost, and benefit.

LEVEL OF EVIDENCE

Therapeutic study, level III.

The pragmatic randomized optimal platelet and plasma ratios trial: what does it mean for remote damage control resuscitation?

BACKGROUND

Implications from the pragmatic, randomize, optimal platelet and plasma ratios (PROPPR) trial are critical for remote damage control resuscitation (DCR). Utilizing DCR principals in remote settings can combat early mortality from hemorrhage. Identifying the appropriate transfusion strategy is mandatory prior to adopting prehospital hemostatic resuscitation strategies.

STUDY DESIGN AND METHODS

The PROPPR study was examined in relation to the following questions: 1) Why is it important to have blood products in the prehospital setting?; 2) Which products should be investigated for prehospital hemostatic resuscitation?; 3) What is the appropriate ratio of blood product transfusion?; and 4) What are the appropriate indications for hemostatic resuscitation?

RESULTS

PROPPR demonstrates that early and balanced blood product transfusion ratios reduced mortality in all patients at 3 hours and death from exsanguination at 24 hours (p = 0.03). The median time to death from exsanguination was 2.3 hours, highlighting the need for point-of-injury DCR capabilities. A 1:1:1 transfusion ratio of plasma:platelets:packed red blood cells increased the percentage of patients achieving anatomic hemostasis (p = 0.006). PROPPR used the assessment of blood consumption score to identify patients likely to require ongoing hemostatic resuscitation. The critical administration threshold predicted patient mortality and identified patients likely to require ongoing hemostatic resuscitation.

CONCLUSION

A balanced resuscitation strategy demonstrates an early survival benefit, decreased death from exsanguination at 24 hours and a greater likelihood of achieving hemostasis in critically injured patients receiving a 1:1:1 ratio of plasma:platelets:PRBCs. This finding highlights the need to import DCR principals to remote locations.

Mortality outcomes in trauma patients undergoing prehospital red blood cell transfusion: a systematic literature review

The value of prehospital red blood cell (RBC) transfusion for trauma patients is controversial. The purposes of this literature review were to determine the mortality rate of trauma patients with hemodynamic instability and the benefit of prehospital RBC transfusion. A 30-year systematic literature review was performed in 2016. Eligible studies were combined for meta-analysis when tests for heterogeneity were insignificant. The synthesized mortality was 35.6% for systolic blood pressure ≤ 90 mmHg; 51.1% for ≤ 80 mmHg; and 63.9% for ≤ 70 mmHg. For patients with either hypotension or emergency trauma center transfused RBCs, the synthesized Injury Severity Score (ISS) was 27.0 and mortality was 36.2%; the ISS and mortality correlation was r = 0.766 (P = 0.0096). For civilian patients receiving prehospital RBC transfusions, the synthesized ISS was 27.5 and mortality was 39.5%. One civilian study suggested a decrement in mortality with prehospital RBC transfusion; however, patient recruitment was only one per center per year and mortality was < 10% despite an ISS of 37. The same study created a matched control subset and indicated that mortality decreased using multivariate analysis; however, neither the assessed factors nor raw mortality was presented. Civilian studies with patients undergoing prehospital RBC transfusion and a matched control subset showed that the synthesized mortality was similar for those transfused (37.5%) and not transfused (38.7%; P = 0.8933). A study of civilian helicopter patients demonstrated a similar 30-day mortality for those with and without prehospital blood product availability (22% versus 21%; P = 0.626). Mortality in a study of matched military patients was better for those receiving prehospital blood or plasma (8%) than the controls (20%; P = 0.013). However, transfused patients had a shorter prehospital time, more advanced airway procedures, and higher hospital RBC transfusion (P < 0.05). A subset with an ISS > 16 showed similar mortality with and without prehospital RBC availability (27.6% versus 32.0%; P = 0.343). Trauma patient mortality increases with the magnitude of hemodynamic instability and anatomic injury. Some literature evidence indicates no survival advantage with prehospital RBC availability. However, other data suggesting a potential benefit is confounded or likely to be biased.

Transfusion of red blood cells in patients with traumatic brain injuries admitted to Canadian trauma health centres: a multicentre cohort study

BACKGROUND

Optimisation of healthcare practices in patients sustaining a traumatic brain injury is of major concern given the high incidence of death and long-term disabilities. Considering the brain's susceptibility to ischaemia, strategies to optimise oxygenation to brain are needed. While red blood cell (RBC) transfusion is one such strategy, specific RBC strategies are debated. We aimed to evaluate RBC transfusion frequency, determinants of transfusions and associated clinical outcomes.

METHODS

We conducted a retrospective multicentre cohort study using data from the National Trauma Registry of Canada. Patients admitted with moderate or severe traumatic brain injury to participating hospitals between April 2005 and March 2013 were eligible. Patient information on blood products, comorbidities, interventions and complications from the Discharge Abstract Database were linked to the National Trauma Registry data. Relative weights analyses evaluated the contribution of each determinant. We conducted multivariate robust Poisson regression to evaluate the association between potential determinants, mortality, complications, hospital-to-home discharge and RBC transfusion. We also used proportional hazard models to evaluate length of stay for time to discharge from ICU and hospital.

RESULTS

Among the 7062 patients with traumatic brain injury, 1991 patients received at least one RBC transfusion during their hospital stay. Female sex, anaemia, coagulopathy, sepsis, bleeding, hypovolemic shock, other comorbid illnesses, serious extracerebral trauma injuries were all significantly associated with RBC transfusion. Serious extracerebral injuries altogether explained 61% of the observed variation in RBC transfusion. Mortality (risk ratio (RR) 1.23 (95% CI 1.13 to 1.33)), trauma complications (RR 1.38 (95% CI 1.32 to 1.44)) and discharge elsewhere than home (RR 1.88 (95% CI 1.75 to 2.04)) were increased in patients who received RBC transfusion. Discharge from ICU and hospital were also delayed in transfused patients.

CONCLUSIONS

RBC transfusion is common in patients with traumatic brain injury and associated with unfavourable outcomes. Trauma severity is an important determinant of RBC transfusion. Prospective studies are needed to further evaluate optimal transfusion strategies in traumatic brain injury.

A 20-Year-Old-Male with Hemorrhagic Shock

Hemorrhagic shock from trauma is a leading cause of morbidity and mortality and commonly encountered by HEMS agencies. Understanding of the management of patients in hemorrhagic shock transported from the scene and interfacility transfers is important for all critical care providers.

Helicopters and injured kids: Improved survival with scene air medical transport in the pediatric trauma population

BACKGROUND

Helicopter emergency medical services (HEMS) are frequently used to transport injured children, despite unclear evidence of benefit. The study objective was to evaluate the association of HEMS compared with ground emergency medical services (GEMS) transport with outcomes in a national sample of pediatric trauma patients.

METHODS

Patients 15 years or younger undergoing scene transport by HEMS or GEMS in the National Trauma Data Bank from 2007 to 2012 were included. Propensity score matching was used to match HEMS and GEMS patients for likelihood of HEMS transport based on demographics, prehospital physiology and time, injury severity, and geographic region. Absolute standardized differences of less than 0.1 indicated adequate covariate balance between groups after matching. The primary outcome was in-hospital survival, while the secondary outcome was discharge disposition in survivors. Conditional logistic regression determined the association between HEMS versus GEMS transport with outcomes while controlling for demographics, admission physiology, injury severity, nonaccidental trauma, and in-hospital complications not accounted for in the propensity score. Subgroup analysis was performed in patients with a transport time of greater than 15 minutes to capture patients with the potential for HEMS transport.

RESULTS

A total of 25,700 HEMS/GEMS pairs were matched from 166,594 patients. Groups were well matched, with all propensity score variables having absolute standardized differences of less than 0.1. In matched patients, HEMS was associated with a 72% increase in odds of survival compared with GEMS (adjusted odds ratio, 1.72; 95% confidence interval, 1.26-2.36; p < 0.01). Transport mode was not associated with discharge disposition (p = 0.47). Subgroup analysis included 17,657 HEMS/GEMS pairs. HEMS was again associated with a significant increase in odds of survival (adjusted odds ratio, 1.81; 95% confidence interval, 1.24-2.65; p < 0.01), while transport mode was not associated with discharge disposition (p = 0.58).

CONCLUSION

Scene transport by HEMS was associated with improved odds of survival compared with GEMS in pediatric trauma patients. Further study is warranted to understand the underlying mechanisms and develop specific triage criteria for HEMS transport in this population.

LEVEL OF EVIDENCE

Therapeutic study, level III.

A Derivation and Validation Study of an Early Blood Transfusion Needs Score for Severe Trauma Patients

Background

There is no existing adequate blood transfusion needs determination tool that Emergency Medical Services (EMS) personnel can use for prehospital blood transfusion initiation. In this study, a simple and pragmatic prehospital blood transfusion needs scoring system was derived and validated.

Methods

Local trauma registry data were reviewed retrospectively from 2004 through 2013. Patients were randomly assigned to derivation and validation cohorts. Multivariate logistic regression was used to identify the independent approachable risks associated with early blood transfusion needs in the derivation cohort in which a scoring system was derived. Sensitivity, specificity, and area under the receiver operational characteristic (AUC) were calculated and compared using both the derivation and validation data.

Results

A total of 24,303 patients were included with 12,151 patients in the derivation and 12,152 patients in the validation cohorts. Age, penetrating injury, heart rate, systolic blood pressure, and Glasgow coma scale (GCS) were risks predictive of early blood transfusion needs. An early blood transfusion needs score was derived. A score > 5 indicated risk of early blood transfusion need with a sensitivity of 83% and a specificity of 80%. A sensitivity of 82% and a specificity of 80% were also found in the validation study and their AUC showed no statistically significant difference (AUC of the derivation = 0.87 versus AUC of the validation = 0.86, P > 0.05).

Conclusions

An early blood transfusion scoring system was derived and internally validated to predict severe trauma patients requiring blood transfusion during prehospital or initial emergency department resuscitation.

Massive transfusion: red blood cell to plasma and platelet unit ratios for resuscitation of massive hemorrhage

PURPOSE OF REVIEW

The aim of this short study is to review recently published data bearing on how to resuscitate massive uncontrolled hemorrhage.

RECENT FINDINGS

New data inform our understanding of the mechanisms of the acute coagulopathy of trauma, the median time to death of trauma patients with uncontrolled hemorrhage, the effects of blood product composition on the coagulation capacity of infused resuscitation mixtures, the outcomes of patients resuscitated according to common massive transfusion protocols in clinical situations associated with massive hemorrhage, and who might benefit from balanced, blood-product-based resuscitation. Importantly, the trial methods, blood bank methods, and primary outcomes of the Pragmatic Randomized Optimal Plasma and Platelet Ratios (PROPPR) trial were recently published. Resuscitation with a 1 : 1 : 1 ratio of units of plasma and platelets to red blood cells was well tolerated and reduced hemorrhagic mortality during resuscitation in the PROPPR trial.

SUMMARY

The bulk of currently available data support the use of a 1 : 1 : 1 ratio for the resuscitation of patients with severe injury, shock, and uncontrolled hemorrhage. The application of this formulaic approach to massive blood product-based resuscitation in other clinical situations is less well supported in the literature.

Helicopter transport improves survival following injury in the absence of a time-saving advantage

BACKGROUND

Although survival benefits have been shown at the population level, it remains unclear what drives the outcome benefits for helicopter emergency medical services (HEMS) in trauma. Although speed is often cited as the vital factor of HEMS, we hypothesized a survival benefit would exist in the absence of a time savings over ground emergency medical services (GEMS). The objective was to examine the association of survival with HEMS compared with GEMS transport across similar prehospital transport times.

METHODS

We used a retrospective cohort of scene HEMS and GEMS transports in the National Trauma Databank (2007-2012). Propensity score matching was used to match HEMS and GEMS subjects on the likelihood of HEMS transport. Subjects were stratified by prehospital transport times in 5-minute increments. Conditional logistic regression determined the association of HEMS with survival across prehospital transport times strata controlling for confounders. Transport distance was estimated from prehospital transport times and average HEMS/GEMS transport speeds.

RESULTS

There were 155,691 HEMS/GEMS pairs matched. HEMS had a survival benefit over GEMS for prehospital transport times between 6 and 30 minutes. This benefit ranged from a 46% increase in odds of survival between 26 and 30 minutes (adjusted odds ratio [AOR], 1.46; 95% CI, 1.11-1.93; P < .01) to an 80% increase in odds of survival between 16 and 20 minutes (AOR, 1.80; 95% CI, 1.51-2.14; P < .01). This prehospital transport times window corresponds to estimated transport distance between 14.3 and 71.3 miles for HEMS and 3.3 and 16.6 miles for GEMS.

CONCLUSION

When stratified by prehospital transport times, HEMS had a survival benefit concentrated in a window between 6 and 30 minutes. Because there was no time-savings advantage for HEMS, these findings may reflect care delivered by HEMS providers.

Pre-trauma center red blood cell transfusion is associated with improved early outcomes in air medical trauma patients

BACKGROUND

Hemorrhage is the leading cause of survivable death in trauma and resuscitation strategies including early RBC transfusion have reduced this. Pre-trauma center (PTC) RBC transfusion is growing and preliminary evidence suggests improved outcomes. The study objective was to evaluate the association of PTC RBC transfusion with outcomes in air medical trauma patients.

STUDY DESIGN

We conducted a retrospective cohort study of trauma patients transported by helicopter to a Level I trauma center from 2007 to 2012. Patients receiving PTC RBC transfusion were matched to control patients (receiving no PTC RBC transfusion during transport) in a 1:2 ratio using a propensity score based on prehospital variables. Conditional logistic regression and mixed-effects linear regression were used to determine the association of PTC RBC transfusion with outcomes. Subgroup analysis was performed for scene transport patients.

RESULTS

Two-hundred and forty treatment patients were matched to 480 control patients receiving no PTC RBC transfusion. Pre-trauma center RBC transfusion was associated with increased odds of 24-hour survival (adjusted odds ratio [AOR] = 4.92; 95% CI, 1.51-16.04; p = 0.01), lower odds of shock (AOR = 0.28; 95% CI, 0.09-0.85; p = 0.03), and lower 24-hour RBC requirement (Coefficient -3.6 RBC units; 95% CI, -7.0 to -0.2; p = 0.04). Among matched scene patients, PTC RBC was also associated with increased odds of 24-hour survival (AOR = 6.31; 95% CI, 1.88-21.14; p < 0.01), lower odds of shock (AOR = 0.24; 95% CI, 0.07-0.80; p = 0.02), and lower 24-hour RBC requirement (Coefficient -4.5 RBC units; 95% CI, -8.3 to -0.7; p = 0.02).

CONCLUSIONS

Pre-trauma center RBC was associated with an increased probability of 24-hour survival, decreased risk of shock, and lower 24-hour RBC requirement. Pre-trauma center RBC appears beneficial in severely injured air medical trauma patients and prospective study is warranted as PTC RBC transfusion becomes more readily available.

Protocol for a systematic review of the clinical effectiveness of pre-hospital blood components compared to other resuscitative fluids in patients with major traumatic haemorrhage

BACKGROUND

There is growing interest in the use of blood components for pre-hospital resuscitation of patients with major traumatic haemorrhage. It has been speculated that early resuscitation with blood components may have benefits in terms of treating trauma-induced coagulopathy, which in turn may influence survival. The proposed systematic review will evaluate the evidence on the clinical effectiveness of pre-hospital blood components (red blood cells and/or plasma or whole blood), in both civilian and military settings, compared with other resuscitation strategies in patients with major traumatic haemorrhage.

METHODS/DESIGN

Standard systematic review methods aimed at minimising bias will be employed for study identification, selection and data extraction. General medical and specialist databases will be searched; the search strategy will combine terms for the population, intervention and setting. Studies will be selected for review if the population includes adult patients with major traumatic haemorrhage who receive blood components in a pre-hospital setting (civilian or military). Systematic reviews, randomised and non-randomised controlled trials and controlled observational studies will be included. Uncontrolled studies will be considered depending on the volume of controlled evidence. Quality assessment will be tailored to different study designs. Both patient related and surrogate outcomes will be considered. Synthesis is likely to be primarily narrative, but meta-analyses and subgroup analyses will be undertaken where clinical and methodological homogeneity exists.

DISCUSSION

Given the increasing use by emergency services of blood components for pre-hospital resuscitation, this is a timely systematic review, which will attempt to clarify the evidence base for this practice. As far as the authors are aware, the proposed systematic review will be the first to address this topic.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42014013794.