title: Transfusion of red blood cells in patients with a prehospital Glasgow Coma Scale score of 8 or less and no evidence of shock is associated with worse outcomes.
abstract: BACKGROUND
  Red blood cell transfusion practices vary, and the optimal hemoglobin for patients with traumatic brain injury has not been established.
  
  
  METHODS
  A retrospective review of data collected prospectively as part of a randomized, controlled trial involving emergency medical service agencies within the Resuscitation Outcomes Consortium was conducted. In patients with a Glasgow Coma Scale (GCS) score of 8 or less without evidence of shock (defined by a systolic blood pressure [SBP] < 70 or SBP of 70 to 90 with a heart rate ≥108), the association of red blood cell transfusion with 28-day survival, adult respiratory distress syndrome-free survival, Multiple Organ Dysfunction Score (MODs), and 6-month Extended Glasgow Outcome Scale (GOSE) score was modeled using multivariable logistic regression with robust SEs adjusting for age, sex, injury severity (Injury Severity Score [ISS]), initial GCS score, initial SBP, highest field heart rate, penetrating injury, fluid use, study site, and hemoglobin (Hgb) level.
  
  
  RESULTS
  A total of 1,158 patients had a mean age of 40, 76% were male, and 98% experienced blunt trauma. The initial mean GCS score was 5, and the initial mean SBP was 134. The mean head Abbreviated Injury Scale (AIS) score was 3.5. A categorical interaction of red blood cell transfusion stratified by initial Hgb showed that when the first Hgb was greater than 10 g/dL, volume of packed red blood cell was associated with a decreased 28-day survival (odds ratio, 0.83; 95% confidence interval [CI], 0.74-0.93; p < 0.01) and decreased adult respiratory distress syndrome-free survival (odds ratio, 0.82; 95% CI, 0.74-0.92; p < 0.01). When the initial Hgb was greater than 10, each unit of blood transfused increased the MODs by 0.45 (coefficient 95% CI, 0.19-0.70; p < 0.01).
  
  
  CONCLUSIONS
  In patients with a suspected traumatic brain injury and no evidence of shock, transfusion of red blood cells was associated with worse outcomes when the initial Hgb was greater than 10.
  
  
  METHODS
  Therapeutic study, level III.
authors.affiliation: Oregon Health & Science University, Portland, Oregon 97239, USA. joel.b.elterman.mil@mail.mil
authors.forename: Joel
authors.initials: J
authors.lastname: Elterman
authors.forename: Karen
authors.initials: K
authors.lastname: Brasel
authors.forename: Siobhan
authors.initials: S
authors.lastname: Brown
authors.forename: Eileen
authors.initials: E
authors.lastname: Bulger
authors.forename: Jim
authors.initials: J
authors.lastname: Christenson
authors.forename: Jeffrey D
authors.initials: JD
authors.lastname: Kerby
authors.forename: Delores
authors.initials: D
authors.lastname: Kannas
authors.forename: Steven
authors.initials: S
authors.lastname: Lin
authors.forename: Joseph P
authors.initials: JP
authors.lastname: Minei
authors.forename: Sandro
authors.initials: S
authors.lastname: Rizoli
authors.forename: Samuel
authors.initials: S
authors.lastname: Tisherman
authors.forename: Martin A
authors.initials: MA
authors.lastname: Schreiber
mesh_terms: D015998:Abbreviated Injury Scale; D000328:Adult; D000368:Aged; D001930:Brain Injuries / Q000175:diagnosis* / Q000401:mortality / Q000628:therapy*; D002423:Cause of Death; D016001:Confidence Intervals; D004311:Double-Blind Method; D004632:Emergency Medical Services / Q000379:methods*; D017707:Erythrocyte Transfusion / Q000009:adverse effects* / Q000379:methods; D005260:Female; D015600:Glasgow Coma Scale; D006454:Hemoglobins / Q000032:analysis; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D011379:Prognosis; D011446:Prospective Studies; D018570:Risk Assessment; D012769:Shock; D016019:Survival Analysis; D013997:Time Factors; D014193:Trauma Centers; D055815:Young Adult
chemical_list: D006454:Hemoglobins