Major Trauma Emergency Blood Transfusions Need Consistency

Globally, bleeding following injury is estimated to be responsible for over two million deaths per year and current treatment strategies focus on the rapid delivery of red blood cells, plasma and other clotting products.

Nearly 5,000 trauma patients sustain major hemorrhage in England and Wales each year and that one-third of those die and delays in blood transfusion practices may contribute to this high death rate. The logistics of providing the correct quantities in the right proportion during the first minutes and hours of emergency care can be extremely challenging.

A team of scientists led by those at the Queen Mary, University of London (London, UK) carried out a prospective observational study from 22 hospitals in the UK, including both major trauma centers and smaller trauma units. Eligible patients received at least four units of packed red blood cells (PRBCs) in the first 24 hours of admission with activation of the massive hemorrhage protocol. The study outcomes were the use of blood components, critical care during hospital stay, and mortality at 24 hours, 30 days and one year.

Overall, only 2% of all patients with massive hemorrhage received what might be considered the optimal transfusion of a high dose of clotting products in conjunction with red blood cells during the first hour of arrival within the Emergency Department. The average time to transfusion of red blood cells was longer than expected, at 41 minutes. Administration of specific blood components to aid with blood clotting such as plasma, platelets and cryoprecipitate was significantly delayed, occurring on average 2-3 hours after admission.

Mortality from bleeding tended to occur early, with nearly two-thirds of all deaths in the first 24 hours. An unexpectedly high number of deaths (7.9%) occurred once the patient left hospital, the reasons for which were unclear. The incidence of major hemorrhage increased markedly in patients over 65 years, who were twice as likely to suffer massive hemorrhage as a result of an injury compared to younger groups. Patients who received a cumulative ratio of fresh frozen plasma to PRBCs of at least 1:2 had lower rates of death than those who received a lower ratio. There were delays in administration of blood. Platelets and cryoprecipitate were either not given, or transfused well after initial resuscitation.

Karim Brohi, MD, a professor of Trauma Surgery and senior author of the study said, “Bleeding is the leading cause of preventable death in trauma. The rapid and consistent delivery of blood, plasma, platelets and other clotting products to trauma patients is essential to maintain clotting during hemorrhage and has been shown to halve mortality. However, we found that only 2% of patients with massive hemorrhage received the optimal type of blood transfusion for their resuscitation. There is a clear opportunity for clinicians to improve the delivery of blood and clotting products during resuscitation for major hemorrhage.” The study was published on February 3, 2016, in the British Journal of Surgery.

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Queen Mary, University of London