title: Multicenter observational prehospital resuscitation on helicopter study.
abstract: Earlier use of in-hospital plasma, platelets, and red blood cells (RBCs) has improved survival in trauma patients with severe hemorrhage. Retrospective studies have associated improved early survival with prehospital blood product transfusion (PHT). We hypothesized that PHT of plasma and/or RBCs would result in improved survival after injury in patients transported by helicopter.
  
  
  
  Adult trauma patients transported by helicopter from the scene to nine Level 1 trauma centers were prospectively observed from January to November 2015. Five helicopter systems had plasma and/or RBCs, whereas the other four helicopter systems used only crystalloid resuscitation. All patients meeting predetermined high-risk criteria were analyzed. Patients receiving PHT were compared with patients not receiving PHT. Our primary analysis compared mortality at 3 hours, 24 hours, and 30 days, using logistic regression to adjust for confounders and site heterogeneity to model patients who were matched on propensity scores.
  
  
  
  Twenty-five thousand one hundred eighteen trauma patients were admitted, 2,341 (9%) were transported by helicopter, of which 1,058 (45%) met the highest-risk criteria. Five hundred eighty-five of 1,058 patients were flown on helicopters carrying blood products. In the systems with blood available, prehospital median systolic blood pressure (125 vs 128) and Glasgow Coma Scale (7 vs 14) was significantly lower, whereas median Injury Severity Score was significantly higher (21 vs 14). Unadjusted mortality was significantly higher in the systems with blood products available, at 3 hours (8.4% vs 3.6%), 24 hours (12.6% vs 8.9%), and 30 days (19.3% vs 13.3%). Twenty-four percent of eligible patients received a PHT. A median of 1 unit of RBCs and plasma were transfused prehospital. Of patients receiving PHT, 24% received only plasma, 7% received only RBCs, and 69% received both. In the propensity score matching analysis (n = 109), PHT was not significantly associated with mortality at any time point, although only 10% of the high-risk sample were able to be matched.
  
  
  
  Because of the unexpected imbalance in systolic blood pressure, Glasgow Coma Scale, and Injury Severity Score between systems with and without blood products on helicopters, matching was limited, and the results of this study are inconclusive. With few units transfused to each patient and small outcome differences between groups, it is likely large, multicenter, randomized studies will be required to detect survival differences in this important population.
  
  
  
  Level II.
authors.affiliation: From the Center for Translational Injury Research (J.B.H., M.D.S., E.E.F., J.S.T., J.M.P., C.E.W.), Division of Acute Care Surgery, Department of Surgery, Medical School, Department of Biostatistics, School of Public Health (M.D.S., S.M.D., T.J.G., S.A., M.Y.), University of Texas Health Science Center at Houston, Houston, Texas; R Adams Cowley Shock Trauma Center, Program in Trauma (D.M.S.), University of Maryland School of Medicine, Baltimore, Maryland; Division of Trauma and Critical Care, Department of Surgery (E.M.B.), School of Medicine, University of Washington, Seattle, Washington; Division of Trauma, Burns and Surgical Critical Care, Department of Surgery (J.D.K.), School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama; Division of Trauma/Critical Care, Department of Surgery (M.G.), College of Medicine, University of Cincinnati, Cincinnati, Ohio; Division of Trauma, Critical Care and Acute Care Surgery (M.A.S.), School of Medicine, Oregon Health & Science University, Portland, Oregon; Division of Trauma, Critical Care, and General Surgery (M.D.Z.), Mayo Clinic, Rochester, Minnesota; Division of Trauma, Critical Care and Emergency Surgery (T.O'K.), Department of Surgery, University of Arizona, Tucson, Arizona; and Division of Trauma and Critical Care (K.I.), University of Southern California, Los Angeles, California.
authors.forename: John B
authors.initials: JB
authors.lastname: Holcomb
authors.forename: Michael D
authors.initials: MD
authors.lastname: Swartz
authors.forename: Stacia M
authors.initials: SM
authors.lastname: DeSantis
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Greene
authors.forename: Erin E
authors.initials: EE
authors.lastname: Fox
authors.forename: Deborah M
authors.initials: DM
authors.lastname: Stein
authors.forename: Eileen M
authors.initials: EM
authors.lastname: Bulger
authors.forename: Jeffrey D
authors.initials: JD
authors.lastname: Kerby
authors.forename: Michael
authors.initials: M
authors.lastname: Goodman
authors.forename: Martin A
authors.initials: MA
authors.lastname: Schreiber
authors.forename: Martin D
authors.initials: MD
authors.lastname: Zielinski
authors.forename: Terence
authors.initials: T
authors.lastname: O'Keeffe
authors.forename: Kenji
authors.initials: K
authors.lastname: Inaba
authors.forename: Jeffrey S
authors.initials: JS
authors.lastname: Tomasek
authors.forename: Jeanette M
authors.initials: JM
authors.lastname: Podbielski
authors.forename: Savitri N
authors.initials: SN
authors.lastname: Appana
authors.forename: Misung
authors.initials: M
authors.lastname: Yi
authors.forename: Charles E
authors.initials: CE
authors.lastname: Wade
mesh_terms: D000328:Adult; D017732:Air Ambulances; D001803:Blood Transfusion / Q000379:methods*; D005260:Female; D006470:Hemorrhage / Q000401:mortality* / Q000628:therapy*; D006801:Humans; D015601:Injury Severity Score; D008297:Male; D008875:Middle Aged; D008887:Military Medicine; D057216:Propensity Score; D011446:Prospective Studies; D012151:Resuscitation / Q000379:methods*; D015996:Survival Rate; D014193:Trauma Centers; D016896:Treatment Outcome