Ultramassive transfusion in an urban level 1 trauma center: a case series

Objective: This case series examines 27 trauma patients who met criteria for ultra massive transfusion protocol (UMTP), defined as receiving over 20 units of packed red blood cells (pRBCs) within 24 hours of admission. Methods: In this case series, 27 trauma patients were identified (≥16 years old) who received over 20 units of pRBCs within the first 24 hours of presentation in the emergency department (2016 to 2020). The data collected included patient demographics, injury type, initial Glasgow Coma Scale (GCS), transfusions, hemostatic adjunct use within 24 hours, lactate, in-hospital complications, length of stay, injury severity score, and mortality. The study was approved by the institutional review board. Descriptive statistics were used to characterize the data. Results: This series primarily consisted of penetrating injuries (79%) and males (81%) with a median age of 31 years. Median admission GCS was 12 (IQR 10 to 15) (survivors: 14 (IQR 14 to 15), non-survivors: 8 (IQR 8 to 15)). Median length of stay was 10 days. Seven patients underwent resuscitative thoracotomy (29% survival), and all 27 patients required operation. Three patients (11%) received cardiopulmonary resuscitation (CPR) during transport, all of whom died. Median transfusion volumes within 24 hours were 36 units of pRBCs, 26 units of fresh frozen plasma (FFP), five units of PLT, and three units of cryoprecipitate.50% of patients received unbalanced ratios (>1.5:1) of pRBCs to FFP, and 60.7% received unbalanced ratios of pRBCs to PLT. Despite aggressive resuscitation, nearly half of the patients died by discharge, demonstrating the severity of their conditions. Conclusion: UMTPs represent a critical component of modern trauma care. Although advancements have been made in protocol development, challenges remain in optimizing outcomes. Admission GCS of 3, age >50 years, resuscitative thoracotomy, and thrombocytopenia are important mortality predictors and should be considered with transport factors when analyzing which patients will benefit from aggressive resuscitation. Level of evidence: IV.