Advertisement

Prehospital plasma is associated with survival principally in patients transferred from the scene of injury: A secondary analysis of the PAMPer trial

      Abstract

      Background

      We sought to characterize if prehospital transfer origin from the scene of injury (SCENE) or from a referral emergency department (REF) alters the survival benefit attributable to prehospital plasma resuscitation in patients at risk of hemorrhagic shock.

      Methods

      We performed a secondary analysis of data from a recently completed prehospital plasma clinical trial. All of the enrolled patients from either the SCENE or REF groups were included. The demographics, injury characteristics, shock severity and resuscitation needs were compared. The primary outcome was a 30-day mortality. Kaplan-Meier analysis and Cox-hazard regression were used to characterize the independent survival benefits of prehospital plasma for transport origin groups.

      Results

      Of the 501 enrolled patients, the REF group patients (n = 111) accounted for 22% with the remaining (n = 390) originating from the scene. The SCENE group patients had higher injury severity and were more likely intubated prehospital. The REF group patients had longer prehospital times and received greater prehospital crystalloid and blood products. Kaplan-Meier analysis revealed a significant 30-day survival benefit associated with prehospital plasma in the SCENE group (P < .01) with no difference found in the REF group patients (P = .36). The Cox-regression verified after controlling for relevant confounders that prehospital plasma was independently associated with a 30-day survival in the SCENE group patients (hazard ratio 0.59; 95% confidence interval 0.39–0.89; P = .01) with no significant relationship found in the REF group patients (hazard ratio 1.03, 95% confidence interval 0.4–3.0).

      Conclusion

      Important differences across the SCENE and REF cohorts exist that are essential to understand when planning prehospital studies. Prehospital plasma is associated with a survival benefit primarily in SCENE group patients. The results are exploratory but suggest transfer origin may be an important determinant of prehospital plasma benefit.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Rhee P.
        • Joseph B.
        • Pandit V.
        • et al.
        Increasing trauma deaths in the United States.
        Ann Surg. 2014; 260: 13-21
        • Cannon J.W.
        Hemorrhagic shock.
        N Engl J Med. 2018; 378: 370-379
        • Li S.R.
        • Guyette F.
        • Brown J.
        • et al.
        Early prehospital tranexamic acid following injury is associated with a 30-day survival benefit: a secondary analysis of a randomized clinical trial.
        Ann Surg. 2021; 274: 419-426
        • Gruen D.S.
        • Guyette F.X.
        • Brown J.B.
        • et al.
        Association of prehospital plasma with survival in patients with traumatic brain injury: a secondary analysis of the PAMPer cluster randomized clinical trial.
        JAMA Netw Open. 2020; 3e2016869
        • Guyette F.X.
        • Brown J.B.
        • Zenati M.S.
        • et al.
        Tranexamic acid during prehospital transport in patients at risk for hemorrhage after injury: a double-blind, placebo-controlled, randomized clinical trial.
        JAMA Surg. 2020; 156: 11-20
        • Sperry J.L.
        • Guyette F.X.
        • Brown J.B.
        • et al.
        Prehospital plasma during air medical transport in trauma patients at risk for hemorrhagic shock.
        N Engl J Med. 2018; 379: 315-326
        • Shackelford S.A.
        • Del Junco D.J.
        Prehospital blood product transfusion and combat injury survival-reply.
        JAMA. 2018; 319: 1167-1168
        • Henriksen H.H.
        • Rahbar E.
        • Baer L.A.
        • et al.
        Pre-hospital transfusion of plasma in hemorrhaging trauma patients independently improves hemostatic competence and acidosis.
        Scand J Trauma Resusc Emerg Med. 2016; 24: 145
        • Anto V.P.
        • Guyette F.X.
        • Brown J.
        • et al.
        Severity of hemorrhage and the survival benefit associated with plasma: results from a randomized prehospital plasma trial.
        J Trauma Acute Care Surg. 2020; 88: 141-147
        • Gruen D.S.
        • Guyette F.X.
        • Brown J.B.
        • et al.
        Characterization of unexpected survivors following a prehospital plasma randomized trial.
        J Trauma Acute Care Surg. 2020; 89: 908-914
        • Gruen D.S.
        • Brown J.B.
        • Guyette F.X.
        • et al.
        Prehospital plasma is associated with distinct biomarker expression following injury.
        JCI Insight. 2020; 5e135350
        • Reitz K.M.
        • Moore H.B.
        • Guyette F.X.
        • et al.
        Prehospital plasma in injured patients is associated with survival principally in blunt injury: results from two randomized prehospital plasma trials.
        J Trauma Acute Care Surg. 2020; 88: 33-41
        • Liu Z.
        • Ayyagari R.C.
        • Martinez Monegro E.Y.
        • et al.
        Blood component use and injury characteristics of acute trauma patients arriving from the scene of injury or as transfers to a large, mature US Level 1 trauma center serving a large, geographically diverse region.
        Transfusion. 2021; 61: 3139-3149
        • MacKenzie E.J.
        • Rivara F.P.
        • Jurkovich G.J.
        • et al.
        A national evaluation of the effect of trauma-center care on mortality.
        N Engl J Med. 2006; 354: 366-378
        • Newgard C.D.
        • McConnell K.J.
        • Hedges J.R.
        • Mullins R.J.
        The benefit of higher level of care transfer of injured patients from nontertiary hospital emergency departments.
        J Trauma. Nov. 2007; 63: 965-971
        • Ho A.M.
        • Dion P.W.
        • Yeung J.H.
        • et al.
        Prevalence of survivor bias in observational studies on fresh frozen plasma:erythrocyte ratios in trauma requiring massive transfusion.
        Anesthesiology. 2012; 116: 716-728
        • Nirula R.
        • Maier R.
        • Moore E.
        • Sperry J.
        • Gentilello L.
        Scoop and run to the trauma center or stay and play at the local hospital: hospital transfer's effect on mortality.
        J Trauma. 2010; 69 (discussion 599–601): 595-599
        • Hill A.D.
        • Fowler R.A.
        • Nathens A.B.
        Impact of interhospital transfer on outcomes for trauma patients: a systematic review.
        J Trauma. 2011; 71 (discussion 1901): 1885-1900
        • Bulger E.M.
        • May S.
        • Kerby J.D.
        • et al.
        Out-of-hospital hypertonic resuscitation after traumatic hypovolemic shock: a randomized, placebo controlled trial.
        Ann Surg. 2011; 253: 431-441
        • Rowell S.E.
        • Meier E.N.
        • McKnight B.
        • et al.
        Effect of out-of-hospital tranexamic acid vs placebo on 6-month functional neurologic outcomes in patients with moderate or severe traumatic brain injury.
        JAMA. 2020; 324: 961-974
        • Sim E.S.
        • Guyette F.X.
        • Brown J.B.
        • et al.
        Massive transfusion and the response to prehospital plasma: it is all in how you define it.
        J Trauma Acute Care Surg. 2020; 89: 43-50
        • Pusateri A.E.
        • Moore E.E.
        • Moore H.B.
        • 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; 155e195085
        • Nathens A.B.
        • Maier R.V.
        • Brundage S.I.
        • Jurkovich G.J.
        • Grossman D.C.
        The effect of interfacility transfer on outcome in an urban trauma system.
        J Trauma. 2003; 55: 444-449
        • Hartl R.
        • Gerber L.M.
        • Iacono L.
        • Ni Q.
        • Lyons K.
        • Ghajar J.
        Direct transport within an organized state trauma system reduces mortality in patients with severe traumatic brain injury.
        J Trauma. 2006; 60 (discussion 1256): 1250-1256
        • Haas B.
        • Stukel T.A.
        • Gomez D.
        • et al.
        The mortality benefit of direct trauma center transport in a regional trauma system: a population-based analysis.
        J Trauma Acute Care Surg. 2012; 72 (discussion 1515–7): 1510-1515