Is There a Role for Prehospital Precision Resuscitation? A Prospective Multi-Institutional Blood Analysis

BACKGROUND: Military experience has paved the way for the development of civilian prehospital (PH) blood programs. Although whole blood (WB) is considered the product of choice for prehospital transfusion, data comparing WB to packed RBC (pRBCs) are lacking. We aimed to compare patient outcomes among multiple fast-paced emergency medical services systems nationwide, hypothesizing that overall patient outcomes with WB would be superior to pRBCs. STUDY DESIGN: This was a prospective multicenter analysis of adult trauma patients who received prehospital transfusion within 9 emergency medical services systems from January 2020 to December 2024. Patients with isolated traumatic brain injury, penetrating injury to the head, or PH cardiac arrest were excluded. The primary endpoint was in-hospital mortality. RESULTS: A total of 339 patients were included, 84 (24.9%) received WB and 255 (75.1%) pRBCs. Penetrating injury was more common in the pRBC group than in the WB group (54.1% vs 39.3%, p = 0.006). No differences were observed between groups in age, injury severity, or initial PH vital signs. In-hospital transfusion requirements at 24 hours were lower in the WB vs pRBC groups: pRBC units (2 vs 3, p < 0.001) and plasma units (0 vs 2, p < 0.001). Kaplan-Meier survival analysis revealed no difference in 24-hour mortality (3.5% vs 6.25%, p = 0.34) or mortality at hospital discharge (7.1% vs 13.7 %, p = 0.11) between WB and pRBCs groups, respectively (KM1). Subgroup analysis of only blunt injury (KM2) showed a survival advantage for WB vs pRBCs (94.1% vs 79.5%, p = 0.02). CONCLUSIONS: Although pRBCs were not inferior to WB overall, prehospital WB was associated with improved survival in blunt trauma patients and reduced subsequent in-hospital transfusion requirements, supporting injury-specific precision resuscitation strategies.