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PREHOSPITAL PLASMA IN INJURED PATIENTS IS ASSOCIATED WITH SURVIVAL PRINCIPALLY IN BLUNT INJURY

RESULTS FROM TWO RANDOMIZED PREHOSPITAL PLASMA TRIALS

Reitz, Katherine M. MD1; Moore, Hunter B. MD, PhD2; Guyette, Frank X. MD, MPH3; Sauaia, Angela MD, PhD2; Pusateri, Anthony E. PhD4; Moore, Ernest E. MD2; Hassoune, Adnan MD1; Chapman, Michael P. MD2; Daley, Brian J. MD5; Miller, Richard S. MD6; Harbrecht, Brian G. MD7; Claridge, Jeffrey A. MD8; Phelan, Herb A. MD9; Brown, Joshua B. MD, MCS1; Zuckerbraun, Brian S. MD1; Neal, Matthew D. MD1; Yazer, Mark H. MD10; Sperry, Jason L. MD, MPH1

Journal of Trauma and Acute Care Surgery: September 12, 2019 - Volume Publish Ahead of Print - Issue - p
doi: 10.1097/TA.0000000000002485
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Introduction Recent evidence demonstrated that prehospital plasma in patients at risk of hemorrhagic shock was safe for ground transport and resulted in a 28-day survival benefit for air medical transport patients. Whether any beneficial effect of prehospital plasma varies across injury mechanism remains unknown.

Methods We performed a secondary analysis using a harmonized dataset derived from two recent prehospital plasma randomized trials. Identical inclusion/exclusion criteria and primary/secondary outcomes were employed for the trials. Prehospital time, arrival shock parameters and 24-hour transfusion requirements were compared across plasma and control groups stratified by mechanism of injury. Stratified survival analysis and Cox hazard regression were performed to determine the independent survival benefits of plasma across blunt and penetrating injury.

Results Blunt patients had higher injury severity, were older and had a lower GCS. Arrival indices of shock and coagulation parameters were similar across blunt and penetrating injury. The percentage of patients with a prehospital time less than 20 mins was significantly higher for penetrating patients relative to blunt injured patients (28.0% vs 11.6%, p<0.01). Stratified Kaplan-Meier curves demonstrated a significant separation for blunt injured patients (n=465, p=0.01) with no separation demonstrated for penetrating injured patients (n=161, p=0.60) Stratified Cox hazard regression verified, after controlling for all important confounders, that prehospital plasma was associated with a 32% lower independent hazard for 28 day mortality in blunt injured patients (HR 0.68, 95% CI 0.47-0.96, p= 0.03) with no independent survival benefit found in penetrating patients (HR 1.16, 95%CI 0.4-3.1, p=0.78).

Conclusion A survival benefit associated with prehospital plasma at 24 hours and 28 days exists primarily in blunt injured patients with no benefit shown in penetrating trauma patients. No detrimental effects attributable to plasma are demonstrated in penetrating injury. These results have important relevance to military and civilian trauma systems.

Original Article

Secondary Analysis

Level of Evidence I

1Department of Surgery, University of Pittsburgh, Pittsburgh, PA

2Department of Surgery, University of Colorado and Denver Health Medical Center, Denver, CO

3Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA

4US Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, Texas

5Department of Surgery, University of Tennessee Health Science Center, Knoxville, TN

6Department of Surgery, Vanderbilt University Medical Center, Nashville, TN

7University of Louisville, Louisville, KY

8MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH

9Department of Surgery, Univ. of Texas Southwestern, Parkland Memorial Hospital, Dallas, TX

10Department of Pathology, Univ. of Pittsburgh and Institute for Transfusion Medicine, Pittsburgh, PA

Presented as an oral presentation at the 78th annual meeting of the American Association For the Surgery of Trauma & Clinical Congress of Acute Care Surgery, Sept 18-21, 2019, Dallas, TX

Conflicts of Interest: The authors have no conflicts of interest to declare and have received no financial or material support related to this manuscript

Corresponding Author: Jason L. Sperry MD, MPH, University of Pittsburgh Medical Center, 200 Lothrop St., Pittsburgh, Pennsylvania 15213, office 412-802 8270, fax 412-647-1448, sperryjl@upmc.edu

Funding: This work was supported by the US Department of Defense (USAMRAA, W81XWH-12-2-0028) and (USAMRAA, W81XWH-12-2-0023)

© 2019 Lippincott Williams & Wilkins, Inc.