Category: Airway Management
Keywords: Hemorrhage, Pre-hospital, Trauma, Shock (PubMed Search)
Enthusiasm for early transfusion of blood products in patients with traumatic shock has increased with increasing availability of pre-hospital blood and plasma and results of studies such as the PAMPer trial of pre-hospital plasma have shown potential mortality benefits. The deployment of prehospital blood for patients in hemorrhagic shock is promising but has significant cost and logistical considerations.
The RePHILL trial was a UK pre-hospital-based study of packed red blood cells and lyophilized plasma versus normal saline in trauma patients with presumed hemorrhagic shock. Patients older than age 16 with an SBP<90 or an absent radial pulse were eligible to get up to 1L of the study intervention. Multiple centers took part in the trial with 1:1 randomization stratified by study center. The primary outcome was a combination of mortality or lactate clearance less than 20% per hour or both.
A total of 432 patients were assigned a study fluid. The population was 82% male, median of 38 years old, with 78% of injuries classified as blunt, and 82% of the presumed hemorrhage classified at non-compressible. This was a very ill population with an average SBP of 73, an average GCS of 7 and an ISS of 36. The average from emergency call to EMS arrival was 30 minutes, average to study intervention was 26 minutes and time from EMS activation to ED arrival was 90 minutes.
The results showed no difference in the primary composite endpoint (64% vs 65%), with no difference in mortality (43% vs 45%) or lactate clearance (50% vs 55%). Interestingly, patients in the blood product arm had similar vital signs, lactate, and INR on ED arrival but received more blood products in the first 24 hours after ED arrival (pRBC 6.34 vs 4.41, p=0.004 and Plasma 5.04 vs 3.37, p=0.002). The was a trend toward improved early mortality at 3hr in the pre-hospital blood group (16% vs 22%, p=0.08).
Prehospital packed red blood cells and lyophilized plasma as compared to saline for traumatic shock did not improve mortality or lactate clearance in a well conducted multicenter RCT.
The use of prehospital blood products is promising but population which benefits, and the optimal type of product and delivery mechanism remain unclear.
Increased blood utilization and lower early mortality in the blood product group may represent alteration in the spectrum of disease that requires different early management.
The reasons for this counterintuitive result are unclear and further trials of whole blood as well as fibrinogen concentrates are ongoing.
Resuscitation with blood products in patients with trauma-related haemorrhagic shock receiving prehospital care (RePHILL): a multicentre, open-label, randomised, controlled, phase 3 trial. Crombie et al. Lancet Hematology. 2022.