In this Prehospital Journal Club Recap, let us take a deep dive into the use of blood products, as well as the adjunct use of automated controlled elevation in CPR.Â
Resuscitation with blood products in patients with trauma-related hemorrhagic shock receiving prehospital care (RePHILL): a multicentre, open-label, randomized, controlled, phase 3 trial
Background
The use of early transfusion in the context of traumatic hemorrhagic shock has widely been used in the military. However, its use in a civilian setting is limited by a lack of evidence supporting the use of blood products at first point of contact in the prehospital environment. The two most recent RCTs investigating the use of prehospital plasma transfusion – COMBAT and PAMPer – have yielded conflicting results.Â
- COMBAT, published in The Lancet in 2018, was a pragmatic RCT involving 144 eligible patients. It compared the administration of 250mL of AB plasma versus an equivalent volume of normal saline (placebo). It demonstrated no significant difference in mortality at 28 days between the two groups. Secondary analysis suggested a potential benefit for circumstances for which longer transport times were expected.
- PAMPer, published in NEJM in 2018, was a phase 3 multi-center cluster-randomized trial involving 564 eligible patients. This trial compared plasma transfusion with crystalloid-based resuscitation and revealed a significantly lower 30-day mortality (9.8% difference) in the plasma group when compared to the control.
The above trials focused on plasma transfusion in the prehospital setting, however, the use of pRBC in this environment is even more sparse.Â
Clinical Question
Is prehospital transfusion of packed red blood cells (PRBCs) and lyophilized plasma (LyoPlas) superior to 0.9% normal saline solution for trauma-related hemorrhagic shock?
Methods
This study was a multicenter, open-label, parallel-group, randomized, controlled, phase 3 trial, which was conducted across four prehospital critical care services in the UK.Â
Results
- Primary Outcome:A composite outcome of mortality between time of injury and hospital discharge or a failure to reach lactate clearance (<20% per hour in the first 2 hours after randomization).
- Key Secondary Outcomes:
- All-cause Mortality within 30 days of injury, and;
- Mortality within 3 hours of injury.
Key results are summarized in the infographics below.
