Time to early resuscitative intervention association with mortality in trauma patients at risk for hemorrhage

Abstract

Background: Hemorrhage is the leading cause of preventable death after injury. Others have shown that delays in massive transfusion cooler arrival increase mortality, while prehospital blood product resuscitation can reduce mortality. Our objective was to evaluate if time to resuscitation initiation impacts mortality.

Methods: We combined data from the Prehospital Air Medical Plasma (PAMPer) trial in which patients received prehospital plasma or standard care and the Study of Tranexamic Acid during Air and ground Medical Prehospital transport (STAAMP) trial in which patients received prehospital tranexamic acid or placebo. We evaluated the time to early resuscitative intervention (TERI) as time from emergency medical services arrival to packed red blood cells, plasma, or tranexamic acid initiation in the field or within 90 minutes of trauma center arrival. For patients not receiving an early resuscitative intervention, the TERI was calculated based on trauma center arrival as earliest opportunity to receive a resuscitative intervention and were propensity matched to those that did to account for selection bias. Mixed-effects logistic regression assessed the association of 30-day and 24-hour mortality with TERI adjusting for confounders. We also evaluated a subgroup of only patients receiving an early resuscitative intervention as defined above.

Results: Among the 1,504 propensity-matched patients, every 1-minute delay in TERI was associated with 2% increase in the odds of 30-day mortality (adjusted odds ratio [aOR], 1.020; 95% confidence interval [CI], 1.006-1.033; p < 0.01) and 1.5% increase in odds of 24-hour mortality (aOR, 1.015; 95% CI, 1.001-1.029; p = 0.03). Among the 799 patients receiving an early resuscitative intervention, every 1-minute increase in TERI was associated with a 2% increase in the odds of 30-day mortality (aOR, 1.021; 95% CI, 1.005-1.038; p = 0.01) and 24-hour mortality (aOR, 1.023; 95% CI, 1.005-1.042; p = 0.01).

Conclusion: Time to early resuscitative intervention is associated with morality in trauma patients with hemorrhagic shock. Bleeding patients need resuscitation initiated early, whether at the trauma center in systems with short prehospital times or in the field when prehospital time is prolonged.

Level of evidence: Therapeutic/Care Management; Level III.

Figure 1.

Conceptual diagram of Time to Early Resuscitative Intervention (TERI). calculation in two patients with identical total prehospital times. The time interval begins at the arrival of emergency medical services (EMS) clinicians. The interval ends at the initiation of an early resuscitative intervention either in the prehospital setting (top scenario) or within 90-minutes of trauma center arrival (middle scenario). For patients not receiving an early resuscitative intervention (bottom scenario), the time interval ends at trauma center arrival as the first potential opportunity to receive an early resuscitative intervention. Note this group of patients was only included if matched based on propensity score to receive an early resuscitative intervention.

Figure 2.

Patient flow diagram for enrollment from the Prehospital Air Medical Plasma (PAMPer) and Study of Tranexamic Acid in Air and ground medical Prehospital transport (STAAMP) trials.