Aaron Spearman

Background: Traumatic hypovolemic shock remains a major cause of preventable early death after injury, and prehospital resuscitation strategy can significantly affect survival¹. Recent trauma literature has moved away from large-volume crystalloid resuscitation because crystalloids do not restore oxygen-carrying capacity or coagulation factors and may worsen dilutional coagulopathy¹. In contrast, prehospital blood product transfusion provides earlier hemostatic and oxygen-delivery support and is associated with decreased mortality¹. Despite this, fewer than 1% of US 911 ground EMS agencies have implemented prehospital blood transfusion programs³. Current literature increasingly suggests outcome advantages with prehospital blood, but important questions remain regarding implementation, access, and which patient populations benefit most, especially in rural systems with prolonged transport times³.

Methods: A comprehensive literature search was conducted using PubMed, focusing on studies published between 2017 and 2025. Keywords included “prehospital blood product transfusion,” “traumatic hemorrhagic shock,” and “prehospital blood versus crystalloid.”

Results: The reviewed literature supports a benefit of prehospital blood product administration over crystalloid-only resuscitation in trauma patients at risk for hemorrhagic shock¹. Comparative findings from an analysis of the groundbreaking Prehospital Air Medical Plasma (PAMPer) study indicated that patients receiving prehospital packed red blood cells and plasma were 62% more likely to survive 30 days when compared to crystalloid-only resuscitation¹. More recent publications further suggest that earlier blood administration in the prehospital setting is beneficial, especially when transport times are greater than 20 minutes⁵. Hemorrhage patients receiving standard crystalloid therapy had a significant increase in mortality when transport times were greater than 20 minutes; this increase in mortality was not observed in patients who received prehospital blood products⁵. The literature also identifies barriers to broader adoption, including storage requirements, cost, wastage concerns, and logistical constraints.³

Conclusions: Prehospital blood product transfusion programs are worth expanding because they enable earlier hemostatic resuscitation, improve physiologic indicators of shock, and are associated with better survival outcomes^1,2. These programs may offer the greatest benefit in rural areas with long transport times, where delays to hospital-based transfusion are greatest and prehospital intervention can close a critical treatment gap⁵. Future research should further evaluate rural-specific outcomes, cost-effectiveness, product wastage reduction, and optimal patient selection to guide broader implementation³.

Works Cited:

[1] Rajesh, A., Barry, L., Giersch, C., Danko, K. L., Bowers, A., Braverman, M., Epley, E., Rose, T., Whole Blood Consortium, S. A., Eastridge, B., & Jenkins, D. (2025). Prehospital whole blood transfusion improves probability of survival over transfusion within one hour of arrival to a trauma center. The American Journal of Surgery, 250, 116530. https://doi.org/10.1016/j.amjsurg.2025.116530

[2] Guyette, F. X., Sperry, J. L., Peitzman, A. B., Billiar, T. R., Daley, B. J., Miller, R. S., Harbrecht, B. G., Claridge, J. A., Putnam, T., Duane, T. M., Phelan, H. A., & Brown, J. B. (2019). Prehospital blood product and crystalloid resuscitation in the severely injured patient: A secondary analysis of the prehospital air medical plasma trial. Annals of Surgery, 273(2), 10.1097/SLA.0000000000003324. https://doi.org/10.1097/SLA.0000000000003324

[3] Schaefer, R. M., Bank, E. A., Krohmer, J. R., Haskell, A., Taylor, A. L., Jenkins, D. H., & Holcomb, J. B. (2024). Removing the barriers to prehospital blood: a roadmap to success. Journal of Trauma and Acute Care Surgery, 97(2). https://doi.org/10.1097/ta.0000000000004378

[4] Duchesne, J., McLafferty, B. J., Broome, J. M., Caputo, S., Ritondale, J. P., Tatum, D., Taghavi, S., Olan Jackson-Weaver, Tran, S., McGrew, P., Harrell, K. N., Smith, A., Nichols, E., Dransfield, T., Marino, M., & Piehl, M. (2024). Every minute matters: Improving outcomes for penetrating trauma through prehospital advanced resuscitative care. The Journal of Trauma and Acute Care Surgery. https://doi.org/10.1097/ta.0000000000004363

‌[5] Sperry, J. L., Guyette, F. X., Brown, J. B., Yazer, M. H., Triulzi, D. J., Early-Young, B. J., Adams, P. W., Daley, B. J., Miller, R. S., Harbrecht, B. G., Claridge, J. A., Puyana, J. C., Alarcon, L. H., & Peitzman, A. B. (2020). Association of prehospital plasma transfusion with survival in trauma patients with hemorrhagic shock when transport times are longer than 20 minutes. JAMA Surgery, 155(2), 122–129. https://doi.org/10.1001/jamasurg.2019.3955

[6] Jouffroy, R., & Vivien, B. (2020). Prehospital Plasma Transfusion and Survival in Trauma Patients With Hemorrhagic Shock. JAMA Surgery. https://doi.org/10.1001/jamasurg.2020.1131

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