title: Low hemorrhage-related mortality in trauma patients in a Level I trauma center employing transfusion packages and early thromboelastography-directed hemostatic resuscitation with plasma and platelets.
abstract: BACKGROUND
  Hemorrhage accounts for most preventable trauma deaths, but still the optimal strategy for hemostatic resuscitation remains debated.
  
  
  METHODS
  This was a prospective study of adult trauma patients admitted to a Level I trauma center. Demography, Injury Severity Score (ISS), transfusion therapy, and mortality were registered. Hemostatic resuscitation was based on a massive transfusion protocol encompassing transfusion packages and thromboelastography (TEG)-guided therapy.
  
  
  RESULTS
  A total of 182 patients were included (75% males, median age 43 years, ISS of 17, 92% with blunt trauma). Overall 28-day mortality was 12% with causes of death being exsanguinations (14%), traumatic brain injury (72%, two-thirds expiring within 24 hr), and other (14%). One-fourth, 16 and 15% of the patients, received red blood cells (RBCs), plasma, or platelets (PLTs) within 2 hours from admission and 68, 71, and 75%, respectively, of patients transfused within 24 hours received the respective blood products within the first 2 hours. In patients transfused within 24 hours, the median number of blood products at 2 hours was 5 units of RBCs, 5 units of plasma, and 2 units of PLT concentrates. Nonsurvivors had lower clot strength by kaolin-activated TEG and TEG functional fibrinogen and lower kaolin-tissue factor-activated TEG α-angle and lysis after 30 minutes compared to survivors. None of the TEG variables were independent predictors of massive transfusion or mortality.
  
  
  CONCLUSIONS
  Three-fourths of the patients transfused with plasma or PLTs within 24 hours received these in the first 2 hours. Hemorrhage caused 14% of the deaths. We introduced transfusion packages and early TEG-directed hemostatic resuscitation at our hospital 10 years ago and this may have contributed to reducing hemorrhagic trauma deaths.
authors.affiliation: Section for Transfusion Medicine, Capital Region Blood Bank, the Department of Anesthesia and TraumaCenter 3193, Centre for Head and Orthopedic, and the Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Surgery, Division of Acute Care Surgery, Centre for Translational Injury Research, CeTIR, University of Texas Medical School at Houston, Houston, Texas.
authors.forename: Pär I
authors.initials: PI
authors.lastname: Johansson
authors.forename: Anne Marie
authors.initials: AM
authors.lastname: Sørensen
authors.forename: Claus F
authors.initials: CF
authors.lastname: Larsen
authors.forename: Nis A
authors.initials: NA
authors.lastname: Windeløv
authors.forename: Jakob
authors.initials: J
authors.lastname: Stensballe
authors.forename: Anders
authors.initials: A
authors.lastname: Perner
authors.forename: Lars S
authors.initials: LS
authors.lastname: Rasmussen
authors.forename: Sisse R
authors.initials: SR
authors.lastname: Ostrowski
mesh_terms: D000328:Adult; D000368:Aged; D016913:Blood Component Transfusion / Q000379:methods*; D005260:Female; D006470:Hemorrhage / Q000401:mortality / Q000628:therapy; D006801:Humans; D008297:Male; D008875:Middle Aged; D010949:Plasma; D017713:Platelet Transfusion / Q000379:methods*; D011446:Prospective Studies; D012151:Resuscitation / Q000379:methods*; D013916:Thrombelastography / Q000379:methods*; D014193:Trauma Centers / Q000706:statistics & numerical data; D014947:Wounds and Injuries