Regional
A holistic, whole pathway approach to resuscitation in trauma haemorrhage
The role of pre-hospital blood transfusion and in-hospital TEG-guided resuscitation with tranexamic acid in optimising outcomes in severe traumatic haemorrhage
In the care of the traumatically injured bleeding patient, timely and effective resuscitation is key to reducing morbidity and mortality. St George’s Hospital, London, has developed a protocol which integrates pre-hospital administration of red blood cells (RBCs), plasma, and whole blood with in-hospital transfusion strategies guided by thromboelastography (TEG). This approach, combined with the use of tranexamic acid (TXA), aims to improve outcomes in patients with traumatic haemorrhage. This article reviews the rationale, implementation, and clinical impact of these interventions.
Trauma remains a leading cause of death worldwide, with 16000 deaths annually in the United Kingdom. Haemorrhage is a primary contributor to preventable deaths. Effective management of haemorrhagic shock hinges on the early and appropriate administration of blood components to restore circulating blood volume, address tissue hypoxia and correct acute traumatic coagulopathy. The London Major Trauma System is a network of 39 hospitals, comprising 4 major trauma centres (including St George’s hospital) and 35 trauma units with land and air ambulance services. At St George’s Hospital, our major haemorrhage protocol incorporates the pre-hospital transfusion of red blood cells, plasma (and, when available, whole blood) by the Helicopter Emergency Medical Services (HEMS) with in-hospital resuscitation techniques to optimise patient outcomes.
Figure 1: The London Major Trauma System
At St George’s Hospital, our major haemorrhage protocol incorporates the pre-hospital transfusion of red blood cells, plasma (and, when available, whole blood) by the Helicopter Emergency Medical Services (HEMS) with in-hospital resuscitation techniques to optimise patient outcomes.
Once the patient arrives in the emergency department, thromboelastography (TEG) is used to guide further transfusion decisions. Additionally, the use of intravenous tranexamic acid (TXA) is a key component in the management of severe trauma patients, reducing clot breakdown and improving survival.
Pre-Hospital Transfusion of Packed Red Blood Cells, Plasma, and Whole Blood:
Pre-hospital transfusion is a cornerstone of trauma management worldwide, especially in patients with severe haemorrhage. Providing this life-saving intervention as early possible mitigates acute traumatic coagulopathy (ATC) and hyperfibrinolysis.
Pre-hospital blood transfusion is carried out by helicopter emergency medical services (HEMS). These teams are equipped with blood components, including packed red blood cells (RBCs), plasma (freeze-dried and pre-thawed fresh frozen plasma) and recently whole blood (in the context of the SWIFT trial). The administration of blood components begins as soon as a significant haemorrhage is identified and continues throughout transport to hospital.
Whole Blood in the Pre-Hospital Setting:
Whole blood is particularly valuable in pre-hospital trauma care as it provides a logistically simple, balanced ratio of red blood cells, plasma, fibrinogen and platelets, which the PROPPR trial suggests improves outcomes in trauma haemorrhage. Historically, resuscitation has included crystalloid fluids and individual blood components for haemorrhagic shock. However, these interventions lack the complexity of whole blood, which contains all the necessary components to support haemostasis, deliver oxygen, and restore circulatory volume; they may also be less physiologic due to manufacturing and storage constraints. The ability to administer whole blood pre-hospital provides a complete haemostatic resuscitation strategy before patients even reach the hospital. St George’s has successfully integrated this pre-hospital whole blood component into its major haemorrhage protocol, whilst awaiting the results of the SWIFT trial.
TEG-Guided Resuscitation in Hospital:
Upon arrival in the emergency department (ED), ED-based thromboelastography (TEG) is used to guide resuscitation. TEG is a point-of-care diagnostic tool that evaluates the coagulation process from clot formation to clot dissolution. It provides real-time information on the patient’s coagulation status, supporting clinicians to correct the coagulopathies detected by transfusing plasma, fibrinogen or platelets as indicated. Conventional coagulation tests, such as the prothrombin time (PT) and activated partial thromboplastin time (aPTT), are less useful in guiding real-time resuscitation decisions. Furthermore, TEG can detect hyperfibrinolysis, a condition often seen in trauma patients, which may require additional antifibrinolytic therapy.
The Role of Tranexamic Acid (TXA):
The antifibrinolytic, tranexamic acid (TXA), has become a crucial part of trauma haemorrhage management. TXA inhibits fibrinolysis, thereby stabilizing clots and reducing bleeding. Using TXA in trauma patients has been shown to decrease mortality, especially when administered early in the course of haemorrhage, predominantly pre-hospital. At St George’s, patients with severe haemorrhage receive two 1-gram boluses of intravenous TXA; the first dose is administered as soon as possible after the trauma and the second dose within 3 hours if ongoing bleeding is present. Large-scale clinical trials, including CRASH-2, have demonstrated that early administration of TXA significantly reduces mortality in trauma patients with severe bleeding; guidelines from the US military and local audit suggest that the second infusion dose of TXA is often incomplete or omitted therefore we deliver this as a bolus.
Integration of Pre-Hospital and In-Hospital Strategies:
Pre-hospital blood transfusion and in-hospital TEG-guided resuscitation produce a comprehensive and dynamic approach to trauma haemorrhage management. Pre-hospital transfusion mitigates early coagulopathy and supports the patient’s arrival at hospital in a more physiologic condition. TEG provides the information necessary to fine-tune resuscitation efforts, ensuring that patients receive the optimal blood component support. This integrated approach minimizes the time between injury, resuscitation and definitive treatment, and optimizes the resuscitation protocol using real-time coagulation data. Patients experience better survival rates and fewer complications related to haemorrhagic shock. This optimisation of blood component use and efficient use of resources leads to a reduction in overall blood component consumption, incidence of massive transfusion, transfusion associated adverse outcomes, and blood component wastage.
Conclusion
The combined use of pre-hospital blood component transfusion, TEG-guided resuscitation, and TXA administration is a cutting-edge approach to trauma haemorrhage care within a mature trauma system. By addressing haemorrhagic shock early in the pre-hospital phase, addressing hyperfibrinolysis and refining in- hospital resuscitation with TEG patient outcomes in severe trauma haemorrhage are improved and blood component use nuanced. The incorporation of these strategies into the holistic approach to trauma resuscitation emphasizes the importance of timely intervention and precise, data-driven decision-making. As evidence continues to support the efficacy of these practices, trauma centres and systems should look to develop these strategies to improve outcomes in trauma haemorrhage.
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