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Three Part Question

In [pre-hospital trauma] are [blood or blood products better then the current standard practice of crystalloid resuscutation] in [reducing patient mortality]?

Clinical Scenario

When faced with a trauma patient in a prehospital setting there has been numerous looks into the use of blood products. The practice of prehospital transfusions has been revitalised by recent military conflicts and has been shown to increase casualty survival leading to a resurrection of military prehospital blood product (PHBP) resuscitation. This has began to apply in a civilian setting with increasing focus on the use of blood and blood products during prehospital trauma. However, when faced with a pre-hospital trauma situation there any prospective and comparative data to support giving blood or blood products over the current standard practice of crystalloid fluid resuscitation?

Search Strategy

Ovid MEDLINE(R) Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid MEDLINE(R) 1946 to Present.

[exp prehospital.mp. OR pre-hospital.mp.] AND [Fluid Therapy/] AND [Blood Transfusion/ or blood products.mp. OR Plasma/] limit to (english language and humans).

Cochrane Central Register of Controlled Trials : Issue 4 of 12, April 2017

[pre-hospital blood transfusion]

Search Outcome

This search strategy produced 20 papers, of these two were duplicates leaving 18 studies. From these there were no prospective comparative or randomised studies comparing crystalloid therapy to the use of blood products meaning there were no completed studies on the subject.
Further search of the Cochrane database showed 4 results, of these two were duplicates leaving 3 results. Two of these were not relevant to the question and were rejected on abstract leaving one study which was a protocol for a unfinished study.
Therefore no appropriate comparison trials were shown to be completed on search of both the MEDLINE or the Cochrane database.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses

Comment(s)

There were no prospective comparative or randomised studies found comparing the use of prehospital blood or blood products versus the use of crystalloid fluids. A large review published in 2015 also did not find any comparative evidence and showed the majority of evidence behind the use of prehospital blood product (PHBP) was of poor standard with limited clinical evidence being predominantly retrospective, observational studies.1 However, there are currently studies in progress looking at this subject. A study protocol entitled 'Prehospital use of plasma in traumatic haemorrhage (The PUPTH Trial): study protocol for a randomised controlled trial.' was published in 2015 and registered in 2014. Though there are no results as yet this has been designed as a prospective, randomised, open-label, non-blinded trial to determine the effect of pre-hospital administration of thawed plasma (TP) on various parameters including mortality as compared to crystalloid resuscitation.2 Also of note there is a further study entitled RePHILL (Resuscitation with Pre-Hospital Blood Products) is a multi-centre randomised controlled trial funded by the National Institute for Health Research (NIHR) Efficacy & Mechanism Evaluation Programme. This study will compare the use of blood products and standard crystalloid fluids looking at the effects on patient mortality in trauma patients with haemorrhagic shock.

Clinical Bottom Line

There were no current published controlled trials comparing prehospital blood product administration versus standard crystalloid therapy for traumatic haemorrhage and the effect of this on patient mortality. There are, however, multiple ongoing trials into the subject which will give a valuable prospective and comparative look at the subject.

References

1. Smith IM, James RH, Dretzke J, Midwinter MJ Prehospital Blood Product Resuscitation for Trauma: A Systematic Review Shock 2016 Jul; 3-6
2. Reynolds PS, Michael MJ, Cochran ED, Wegelin JA, Spiess BD Prehospital use of plasma in traumatic hemorrhage (The PUPTH Trial): study protocol for a randomised controlled trial. Trails 2015 Jul