BACKGROUND:Despite two large randomized controlled trials (RCT) designed to assess tranexamic acid (TXA) for traumatic brain injury (TBI) patients, its use and optimal dosing strategy in TBI remains uncertain. We sought to assess functional and mortality outcomes associated with prehospital TXA administration for TBI patients using Bayesian techniques. METHODS:We performed a post hoc analysis of the prehospital TXA for TBI RCT where TBI patients received TXA as a 1-g bolus followed by a 1-g infusion (standard), 2-g bolus (bolus), or placebo. Bayesian regression models were created to assess the association of early prehospital TXA administration in TBI patients using posterior probabilities for 6-month functional outcomes, as well as 28-day and 6-month mortality. RESULTS:Patients receiving prehospital TXA (standard or bolus) displayed a 78.1% probability of having improved functional neurologic outcomes at 6 months compared with placebo. When compared with placebo, the Bolus cohort displayed a 95.3% probability of improved functional neurologic outcomes at 6 months, a 95.3% probability of decreased mortality at 28 days, and a 70.7% probability of decreased mortality at 6 months. The Standard cohort displayed a less than 50% probability of benefit compared with placebo for all outcomes measured. CONCLUSION:A prehospital 2 g TXA bolus dosing strategy demonstrated a high probability of benefit compared with both placebo and Standard cohorts for functional neurologic and mortality outcomes in patients with moderate to severe TBI. ( J Trauma Acute Care Surg . 2026;100: 879-885. © 2026 American Association for the Surgery of Trauma.). LEVEL OF EVIDENCE:Therapeutic; Level III.

BACKGROUND:Interfacility transfers for facial trauma are common but often avoidable. However, the magnitude of these potentially avoidable interfacility transfers (PAITs), which can strain trauma systems and incur avoidable costs to the patients, remains unknown. This study aimed to quantify the burden of PAITs for isolated facial trauma in the US. STUDY DESIGN:A retrospective analysis using the 2022 Nationwide Emergency Department Sample was performed. Patients aged 16 years and older with isolated facial injuries were identified using ICD-10-CM codes and the Abbreviated Injury Scale. A multiple logistic regression model was developed from level I trauma center (TC) data to predict emergency department home discharge, internally validated, and applied to transfers from level III or non-TCs to identify PAITs based on high predicted discharge probabilities. RESULTS:Among 856,197 patients with isolated facial trauma, 661,149 were initially treated at level III or non-TCs, of whom 2.4% were transferred to higher-level facilities. Using a Youden Index-derived predicted home discharge probability of greater than or equal to 0.946, 43.2% (95% CI 40.9% to 45.4%) of these transfers were classified as potentially avoidable. These transfers were more common among younger, male individuals, White race, those with private insurance, urban residence and those injured by being struck, treated in Southern hospitals, or private not-for-profit facilities. CONCLUSIONS:A substantial proportion of interfacility transfers for isolated facial trauma may be avoidable when benchmarked against discharge practices at level I TCs. These findings highlight a critical opportunity to optimize secondary triage decision-making, possibly in conjunction with telehealth consultations, before patient transfer.

Importance:Balanced transfusion is a cornerstone of modern hemorrhage resuscitation, yet national adoption patterns and hospital practice variation remain poorly characterized, particularly following increasing use of whole blood (WB). Objective:To evaluate trends, between-hospital variation, and patient and institutional factors associated with balanced component and WB transfusion in US trauma centers. Design, Setting, and Participants:This retrospective cohort study of adult trauma patients in hemorrhagic shock receiving blood transfusion within 4 hours of hospital arrival used data from the Trauma Quality Improvement Program (2018-2024). Multilevel mixed-effects logistic regression was used to evaluate patient and hospital characteristics associated with balanced component and WB use and quantify hospital-level variation. Exposure:Patient demographic and injury characteristics, hospital structural characteristics, and calendar year. Main Outcomes and Measures:The primary outcome was balanced component and WB use within 4 hours of arrival, defined by standardized ratios of plasma to red blood cells and platelet to red blood cells or receipt of WB. Temporal trends and facility variation were assessed using adjusted odds ratios (ORs), intraclass correlation coefficients, and median ORs. Results:The study included 71 997 patients treated at 650 trauma centers (197 [30.3%] American College of Surgeons-verified level I). The median (IQR) age was 36.0 (26.0-52.0) years, 54 889 patients (76.2%) were male, and 45 185 patients (62.8%) sustained blunt injury. Balanced component and WB transfusion increased from 12.4% (918 transfusions) in 2018 to 37.6% (4244 transfusions) in 2024 (adjusted OR, 5.33; 95% CI, 4.88-5.81), largely corresponding to increasing WB adoption after 2020, whereas component-based balanced transfusion remained relatively stable. Significant between-hospital variation persisted after adjustment. Hospital-level differences accounted for 24% of variation in balanced component and WB use (intraclass correlation coefficient, 0.24; 95% CI, 0.21-0.26). Male sex, helicopter transport, and treatment at larger hospitals were associated with higher odds of balanced component and WB use, whereas major hemorrhage control surgery and severe torso injuries were negatively associated, despite higher total transfusion volumes. Conclusions and Relevance:In this retrospective cohort study of trauma patients at risk of hemorrhagic shock, the use of balanced component and WB use increased from 2018 to 2024, reflecting increasing WB adoption. Substantial between-hospital variation persisted. These findings can inform evaluation of hospital-level variation and future implementation of balanced transfusion practices across trauma centers.

BackgroundEmergency department (ED)-based teletrauma service may improve access to trauma expertise, especially in rural areas. However, its impact on patient outcomes remains unclear due to limited understanding of how and what type of care is delivered. The objective of this study was to characterize how EDs in the United States (US) use teletrauma services in clinical practice.MethodsNon-federal/non-specialty EDs, that previously reported using teletrauma, were surveyed in the 2023 National Emergency Department Inventory Teletrauma Survey. The survey was developed and mailed/emailed to ED directors up to two times; nonresponders were contacted via telephone. Survey assessed structural and process measures including staffing, workflows, clinical care, and resource availability. Descriptive statistics were used.ResultsAmong 378 EDs that reported using teletrauma in 2022, 310 responded (82%). Only 68% (211/310) reported using teletrauma in 2023. Most teletrauma-using EDs (TT-EDs) used the service once a month or less (58%), were staffed by non-emergency medicine (EM)-trained providers for in-person care (69%) and EM-trained physicians for remote care (72%). Consults were usually initiated at the discretion of the in-person provider (80%) and often after the patient's arrival to the ED (46%). Clinical applications included decision-support for interfacility transfers (78%), resuscitation-support (71%), documentation (69%) and remote procedural-support (64%) for patients of all ages. Some TT-EDs received trauma education from teletrauma-providing sites (30%), but few reported receiving resources, such as blood products (4%).ConclusionTeletrauma is not widely used in US EDs. Even when capabilities exist, teletrauma use remains limited and insufficiently adapted to rural trauma care.

BACKGROUND:Previous studies suggest that in children with hemorrhagic shock following injury, prehospital blood transfusion improves survival. Quantifying and understanding the current demand for blood transfusion will help us improve the use and availability of prehospital blood for pediatric patients. This study sought to describe the current demand for and utilization of prehospital blood resuscitation following motor vehicle crash (MVC) in pediatric trauma populations from 2020 to 2023. STUDY DESIGN AND METHODS:Hypotensive patients ≤14 years after MVC included in the National Emergency Medical Services Information System (NEMSIS) from 2020 to 2023 were identified. Hemodynamic instability was based on age-defined systolic blood pressure and heart rate parameters. Total number and percentage of children who received prehospital blood transfusion, including components or whole blood, were calculated. RESULTS:The database included 391,764 children involved in an MVC. Of these, 1913/391,764 (0.5%) were potentially eligible for prehospital blood transfusion based on prehospital hemodynamic status, yet of the 1913 patients, only 39/1913 (2%) received prehospital blood. Eligible patients were generally older than 10 years (64%) and MVCs occurred in urban areas (77%). DISCUSSION:Only 2% of hemodynamically unstable pediatric MVC patients received prehospital blood. Prehospital blood resuscitation is underutilized in pediatric MVC populations, suggesting an urgent need for focused evaluation to identify barriers and promote increased utilization.

This cross-sectional study determines the additional population access to trauma care expertise provided by telehealth for trauma in emergency departments and provides updated national estimates of trauma center access.

BACKGROUND:Hemorrhage remains the leading cause of preventable traumatic deaths, with many fatalities occurring before hospital arrival. Although geographic differences in prehospital time (PHT) are recognized, contemporary national estimates and their implications for resuscitation readiness are not well defined. This study aimed to characterize geographic variation in PHT among trauma patients at risk of hemorrhagic shock to inform strategies for earlier intervention. STUDY DESIGN AND METHODS:We analyzed 2020-2023 data from the National Emergency Medical Services (EMS) Information System (NEMSIS) and included trauma patients aged ≥16 years at risk of hemorrhagic shock, defined as shock index (heart rate/systolic blood pressure) ≥1 at the scene. PHT was defined as the interval from dispatch to hospital arrival and compared across urbanicity (urban, suburban, rural, wilderness) and transport mode (ground or air). RESULTS:Among 939,335 eligible encounters, the median prehospital time (PHT) differed significantly across urbanicity categories, increasing progressively from urban to wilderness regions (urban 39 min [IQR 30-51], suburban 45 [32-63], rural 50 [34-71], wilderness 56 [37-78]; p < .001). All three components of PHT-system response, scene, and transport time-were longer in rural and wilderness. Total PHTs remained stable, with only minor year-to-year variation. Air PHT was consistently longer than ground PHT (p < .001) and showed no temporal improvement across 2020-2023. DISCUSSION:National EMS data show persistently prolonged prehospital times for trauma patients at risk of hemorrhagic shock, especially in rural and wilderness areas. Bringing transfusion capability closer to patients through prehospital blood programs may be critical to reducing time-dependent mortality.

Calcium disturbances are common in patients with traumatic injuries, exacerbated by shock and blood product resuscitation. Recently, empiric calcium supplementation has been recommended with the first unit of blood transfusion, despite a lack of data supporting this practice. We hypothesize that there are risks associated with calcium administration in patients receiving small volume transfusion. This is a retrospective review of patients admitted to our Level 1 trauma center from 2018 to 2024 who received 1–3 units of red blood cells (RBCs). Patients were stratified by calcium levels and whether they received early calcium supplementation. A logistic regression was used to estimate odds ratios for the association between calcium levels, calcium supplementation, and outcomes. The primary outcome was in-hospital mortality. Secondary outcomes included acute kidney injury, myocardial infarction, acute respiratory distress syndrome, and venous thromboembolism. The model was adjusted for age, sex, ISS and shock index. A total of 2,680 patients were included. When stratified by calcium levels and supplementation status, patients were similar in terms of age, sex, mechanism and injury severity score, but shock index was higher among patients receiving calcium supplementation. After adjustment, hypocalcemic patients who received calcium supplementation had higher odds of developing acute kidney injury, acute respiratory distress syndrome, deep vein thrombosis, and pulmonary embolism (all p < 0.05). In trauma patients who received 1–3 units of RBCs, early calcium supplementation was associated with adverse outcomes. The use of early, empiric calcium supplementation in conjunction with minimal transfusion should be carefully considered.

BACKGROUND:Blood transfusion before arrival at a hospital reduces mortality from traumatic hemorrhage and shock. Whether transfusion with whole blood is more beneficial than transfusion with blood components is uncertain, as are the effects of the length of time that blood products are in storage between donation and transfusion. METHODS:In this pragmatic, multicenter, phase 3, cluster-randomized trial, we assigned 44 air medical bases in a 2:1 ratio to the use of up to 2 units of whole blood or as-indicated blood components (plasma, red cells, or both) for prehospital transfusion in trauma patients during 1-month blocks. The primary outcome was death from any cause within 30 days after randomization. An observational substudy assessed outcomes according to the storage age of whole blood. RESULTS:Of 1020 eligible patients transported to hospitals by the air bases, 715 were assigned to receive whole blood and 305 to receive blood components; 695 and 298, respectively, were included in the primary analysis. Mortality at 30 days was 25.9% in the whole-blood group and 20.5% in the component group (adjusted odds ratio, 1.24; 95% confidence interval [CI], 0.87 to 1.76; P = 0.24). No substantial between-group differences in adverse events were observed. In the observational substudy, 30-day mortality was 27.1% among 210 patients who received whole blood with a storage age of 15 to 21 days and 26.4% among 443 patients who received whole blood with a storage age of 1 to 14 days (adjusted odds ratio, 0.99; 95% CI, 0.74 to 1.32). CONCLUSIONS:In injured patients with hemorrhagic shock, the use of whole blood for prehospital transfusion did not result in lower 30-day mortality than the use of blood components. (Funded by the Defense Health Agency Research Technology Portfolio Management, Combat Casualty Portfolio; TOWAR ClinicalTrials.gov number, NCT04684719.).

Introduction Previous studies suggested that type O blood may be associated with increased mortality and/or thrombotic complications among trauma patients. The purpose of this analysis was to evaluate the relationship between endogenous blood type, mortality, and complications among patients receiving massive transfusions, using data from the Pragmatic Randomized Optimal Platelet and Plasma Ratios trial. Materials and Methods This was a secondary analysis of the Pragmatic Randomized Optimal Platelet and Plasma Ratios trial that included patients with the reported blood type (A, AB, B, or O) data. Outcomes were early and late mortality and clinical complications. Endogenous von Willebrand Factor (vWF) antigen levels, vWF activity, and factor VIII levels were measured with admission labs and compared. Logistical regression was used to assess associations between mortality and blood type. Results Among 680 patients, 655 who had admission blood type data were included. 322 (49.2%) were type O, 186 (28.4%) were type A, 27 (4.1%) were type AB, and 120 (18.3%) were type B. The mean age, gender distribution, mechanism of injury, injury severity, and injury patterns were similar between blood types. There were significant racial and ethnic differences (P < 0.001 and P < 0.0018, respectively), and patients with endogenous type O blood had decreased levels of vWF activity and vWF antigen (P = 0.022 and P = 0.016, respectively). Logistical analyses showed no significant associations between blood type and complications, and type O blood was not associated with increased mortality. Conclusions We found that endogenous blood type was not associated with increased mortality or clinical complications in severely injured patients requiring massive transfusion based on the data from a large multicenter trial.

Objectives:Early detection of intracranial hematoma (ICH) expansion is critical to improving outcomes in patients with traumatic brain injuries (TBIs). The Infrascanner 2000 (InfraScan Inc) is a US Food and Drug Administration-cleared device capable of detecting ICHs. We report our preliminary experience of conducting a prospective evaluation of serial infrascans to evaluate the diagnostic performance of the device for monitoring changes in ICH size. Methods:A single-center prospective observational study was conducted. We included patients with traumatic ICHs detected on admission computed tomography (CT) scanning, and conducted hourly infrascans until a second CT scan had been performed. We evaluated the practicability of enrollment, conducting hourly infrascans, and the diagnostic performance of the device. Results:We approached 134 patients, or their legally authorized representatives, and enrolled 62 (46%). Most index hematomas were small (median, 2.5 mL, IQR, 0.6-7.0 mL), and 23 experienced enlargement. Hourly infrascan assessments were performed successfully in the majority of patients (300 of 340 scans, 88%). The most common reasons for scans not being performed, or not performed on time, were technical issues with the devices (17 scans, 40%), the presence of dressings and bandages (2 scans, 5%), and patients being taken for other investigations or treatment (12 scans, 31%). Given the sample size, the small size of enrolled patients' ICHs, and the low proportion that experienced enlargement, it was not possible to demonstrate the ability of the Infrascanner to detect expansion. Conclusion:This preliminary study confirms the practicability of conducting a prospective evaluation of the Infrascanner for the purpose of serially monitoring the size of ICHs in trauma patients.

BACKGROUND:Supplemental oxygen is essential in caring for adults with acute thermal burns but can expose patients to excess inspired oxygen. We sought to determine the safety and effectiveness of targeting normoxemia (peripheral oxygen saturation [SpO 2 ] 90-96%) in adults with acute thermal burns admitted to a specialized burn unit. We hypothesized that targeting normoxemia would increase the number of supplemental oxygen-free days (SOFDs) and safely reduce exposure to hyperoxemia. METHODS:In this multicenter cluster-randomized, stepped-wedge trial, we randomized six US burn centers to cross over from usual care to targeted normoxemia at three-month intervals between January 15, 2021, and October 15, 2022. In usual care, supplemental oxygen was determined by treating clinicians. In targeted normoxemia, we specified decreasing administered supplemental oxygen whenever SpO 2 was >96%. The primary outcome was SOFD, defined as the number of days alive and not receiving supplemental oxygen through Day 28. Safety outcomes included hypoxemia (SpO 2 < 88%), in-hospital mortality, and adverse events. RESULTS:The 1,437 enrolled patients were mean age 48 years, 26% female, 38% with full-thickness burns, and 11% mean total body surface area burned. The proportion of time spent in normoxemia increased from 77% in the usual care group to 81% in the targeted normoxemia group. Time spent with hyperoxemia (SpO 2 > 96%) decreased from 22% to 17%, and hypoxemia was similar between groups (0.7% vs. 0.8%). The raw mean number of SOFD was 18.8 days for targeted normoxemia and 17.2 days for usual care (adjusted mean difference [aMD], 0.90 days; 95% confidence interval [CI], -0.77 to 2.57; p = 0.29). Hospital-free days through Day 90 were greater among the targeted normoxemia group (71 days) than the usual care group (70 days) (aMD, 3.47 days; 95% CI, 0.19-6.76). In-hospital mortality to Day 90 occurred in 36 (5.7%) targeted normoxemia patients and 65 (8.1%) usual care patients (adjusted hazard ratio [aHR], 0.66; 95% CI, 0.31-1.42). CONCLUSION:Targeting normoxemia did not increase supplemental oxygen-free days among adults with acute thermal burns, but safely maintained clinical outcomes. LEVEL OF EVIDENCE:Therapeutic Care/Management; Level I. TRIAL REGISTRATION:ClinicalTrials.gov Identifier: NCT04534972.

Importance Supplemental oxygen is fundamental to caring for critically injured adults but can expose them to excess inspired oxygen. Objective To determine the safety and effectiveness of targeting normoxemia in critically ill trauma patients. Design, Setting, and ParticipantsThis multicenter, stepped-wedge, cluster randomized clinical trial compared targeted normoxemia (defined as a peripheral oxygen saturation [Spo2] of 90% to 96%) with usual care among adult trauma patients admitted to an intensive care unit (ICU) at 8 level I trauma centers across the US. These trauma centers were randomized at 3-month intervals when they crossed over from usual care to targeting normoxemia. Eligible patients were enrolled between July 15, 2020, and November 14, 2022. All statistical analyses were performed from April 2023 to November 2024 according to intention-to-treat approach. Intervention In the usual care group, supplemental oxygen was determined by treating clinicians. In the targeted normoxemia group, a multimodal educational and informatics intervention encouraged decreasing the supplemental oxygen administered whenever Spo2 exceeded 96%. Main Outcomes and Measures The primary outcome was supplemental oxygen-free days (SOFDs), defined as the number of days alive and not receiving supplemental oxygen through day 28. Safety outcomes included hypoxemia (defined as Spo2 <88%) during the ICU admission, in-hospital mortality, and adverse events. Results A total of 12 487 patients were enrolled (mean [SD] age, 51.7 [21.1] years; 8799 males [70.5%]; mean [SD] Injury Severity Score, 19.6 [12.0]). The proportion of ICU time spent in normoxemia increased from 56.2% in the usual care group to 71.6% in the targeted normoxemia group. Hyperoxemia (defined as Spo2 >96%) decreased from 42.4% in the usual care group to 26.7% in the targeted normoxemia group, and hypoxemia was similar between groups (1.1% vs 1.1%). The raw mean (SD) number of SOFDs was 19.6 (10.3) days for the targeted normoxemia group and 17.5 (10.4) days for the usual care group (adjusted mean difference [AMD], 0.32 [95% CI, -0.37 to 1.00] days; P = .30). Among patients not receiving mechanical ventilation at ICU admission, mean SOFDs were greater in the targeted normoxemia group than in the usual care group (22.6 [8.30] days vs 20.6 [8.86] days; AMD, 0.75; 95% CI, 0.00-1.50 days). The mean (SD) time for weaning to room air was 1.6 (3.2) days for the targeted normoxemia group and 2.7 (4.0) days for the usual care group (adjusted hazard ratio [AHR], 1.23; 95% CI, 1.13-1.33 days). In-hospital mortality to day 90 occurred in 563 patients (9.9%) in the targeted normoxemia and 732 patients (10.7%) in the usual care group (AHR, 1.05; 95% CI, 0.83-1.33). No adverse events were reported in either group. Conclusions and Relevance This randomized clinical trial showed that targeting normoxemia did not increase the number of SOFDs but safely reduced supplemental oxygen use among critically ill trauma patients. Trial RegistrationClinicalTrials.gov Identifier: NCT04534959

Background Trauma recidivism refers to patients who are injured repeatedly. There has been no evaluation of trauma recidivism in England and Wales. We hypothesize that, because population demographics and predominant trauma mechanism differ from other studied populations, the typical demographics of patients suffering repeated trauma would differ. Our aim was to determine the demographic and injury characteristics, and outcomes of patients suffering repeated trauma.Methods This was a national, retrospective, population-based cohort study of patients included in the prospectively collected Trauma Audit & Research Network’s (TARN) National Trauma Registry for England and Wales between 2019 and 2020. We defined recidivism as a second admission, with different injuries, within 1 year of the initial admission. Analysis was descriptive.Results 2517 patients (5136 admissions) were included. Median age at first admission was 81 years, and 1888 (75%) were ≥65 years. 1301 (52%) were female. The most common mechanism of injury at first and second admission was a fall ≤2 m (2159 86%, 2237 89%). 2035 (81%) suffered a fall ≤2 m on both admissions. Patients with severe injury increased from 838 (33%) to 982 (39%) from first to second admission. Patients discharged home decreased from 1776 (71%) to 1449 (58%) from first to second admission. Mortality on 2nd admission was 10.2%.Conclusions In England and Wales, trauma recidivism consists primarily of elderly patients who repeatedly suffer low-energy falls. It follows that prevention strategies should consist of greater and earlier involvement of multidisciplinary team input including geriatric physicians and allied health professionals, for anyone ≥65 who fulfills the criteria for TARN inclusion.Level of evidence Level III.

Hemorrhage is the most common cause of potentially preventable death after injury. Balanced transfusion with red blood cells, plasma, and platelets (component therapy, CT) has been shown to reduce mortality, and is the standard of care. Low-Titer Group O Whole Blood (LTOWB) is an attractive alternative to CT, but existing evidence comprises observational studies, and a small single center pilot randomized controlled trial, which evaluated a type of whole blood that is no longer in use. The aim of the “Trauma Resuscitation with Low-Titer Group O Whole Blood Or Products” (TROOP) trial is to compare the effectiveness and safety of LTOWB and CT in critically injured patients predicted to require a large volume transfusion. This is a pragmatic, multicenter, Bayesian, sequential non-inferiority/superiority, randomized clinical trial, performed within 15 level I trauma centers in the United States. We aim to randomize 1,100 injured patients to resuscitation with either CT or LTOWB. The primary outcome is 6-h mortality. Secondary outcomes include 24-h and 30-day or hospital mortality (whichever is earlier); prespecified complications; adjudicated cause of death; time to death; length of stay (ICU and hospital); and hospital-, ventilator- and ICU-free days; the incidence of major surgical procedures; time to hemostasis in those undergoing procedures with a hemostatic component; number and type of blood products used until hemostasis is achieved (and randomized products are discontinued), as well as after hemostasis has been achieved, to 24 h post-admission; discharge destination and functional status and quality of life at hospital discharge or 30 days, as measured by Glasgow Coma Scale (GCS) and EuroQol (EQ-5D) quality of life measurement. This large multicenter clinical trial will contribute high-level evidence on the effectiveness of Low-Titer Group O Whole Blood in the in-hospital management of trauma patients predicted to require a large volume transfusion. Trial registration National Clinical Trial Identified Number: NCT05638581. Clinical trial registry: https://clinicaltrials.gov/study/NCT05638581 First submitted 2022–11-08.

Background ‘Exception from informed consent’ research requires community consultation to ensure that the views of the local population have been considered. Using market research companies to distribute surveys across local populations is attractive because it ensures adequate response rates. It is not known whether individuals who respond to surveys are typical of the targeted communities. The purpose of this study is to compare the demographics of the survey respondents with that of the general population in the same area.Methods This is an analysis of data collected as part of the ‘Trauma Resuscitation with Group O Whole Blood or Products’ (TROOP) trial. The surveys used a commercial market research service to reach the communities of interest and consisted of 18 questions designed to evaluate respondents’ willingness to be enrolled in the TROOP trial and the demographics of survey respondents.Results Catchment populations varied from 0.5 to 9.4 million residents, with a total of 33.5 million. The racial and ethnic composition of the population (and the survey respondents, in brackets) was 44.8% (57.0%) white, 25.7% (13.4%) Hispanic, 12.7% (19.4%) black, 8.0% (2.5%) multiracial, 7.9% (4.4%) Asian, 0.7% (0.9%) Native American, and 0.2% (0.5%) Islanders. Of the male population (and survey respondents, in brackets), 12.2% (15.3%) were aged 18years to 24 years, 20.5% (22.3%) aged 25 years to 34 years, 18.1% (24.9%) aged 35 years to 44 years, 16.3% (18.5%) aged 45 years to 54 years, 15.5% (14.8%) aged 55 years to 64 years, and 17.4% (4.3%) aged 65 years and over. Of the female population (and survey respondents, in brackets), 11.0% (18.5%) were aged 18 years to 24 years, 18.4% (22.6%) aged 25 years to 34 years, 16.4% (23.5%) aged 35 years to 44 years, 15.0% (17.3%) aged 45 years to 54 years, 18.5% (14.1%) aged 55 years to 64 years, and 20.6% (3.9%) aged 65 years and over.Conclusions For this trial, using a market research company to distribute community surveys resulted in respondents that are broadly representative of the geographic areas where the trial will be conducted, except for individuals over the age of 65 years and older. This finding provides reassurance to investigators and institutional review boards that the views expressed by respondents are representative of the population where the trial will be conducted.Level of evidence III

Prehospital blood transfusions result in a significant reduction in mortality risk for injured patients in hemorrhagic shock; however, prehospital blood transfusions have not been widely implemented across the United States. Thus, a paucity of data surrounding the impact of achieving near-complete population-level access to this resource exists. We aimed to determine the number of lives that could potentially have been saved among injured patients in hemorrhagic shock between 2020 and 2023 had prehospital blood products (blood components or whole blood, pBP) been fully implemented. We performed a retrospective review of the National Emergency Medical Services Information System (NEMSIS) from 2020 to 2023 for all trauma patients ≥16 years. Patients with prehospital systolic blood pressure <90 mmHg and heart rate >108 beats per minute, or a systolic blood pressure <70 mmHg, and who did not receive pBP products were included in the analysis. Potential lives saved were calculated using mortality and risk ratio estimates (RR) from previously published studies, assuming 100% nationwide access to pBP. A series of models were developed incorporating varying RR, mortality rate assumptions, and nationwide access to pBP to encompass a wide range of scenarios. A total of 260,472 patients met our inclusion criteria. Using a 22.1% 24-h mortality rate and an RR of 0.629, 21,356 deaths over the four-year study period could have potentially been saved with the nationwide implementation of pBP. Transfusion of pBP offers the potential to save thousands of injured patients lives. Efforts toward making policy-level interventions aimed at increasing the adoption and availability of pBP should be sought.

Objective:The purpose of this study was to evaluate for differences in the baseline mortality rates of patients injured by different mechanisms, in the Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial, and compare their responses to 2 resuscitation paradigms. Our hypothesis was there are differences between the blunt and penetrating trauma patients, with regard to baseline and effect size. Background:Previous research including clinical trials and basic science research suggests differences in mortality among patients injured by blunt or penetrating mechanisms, although differences between these 2 mechanisms-both baseline and effect size-are rarely considered explicitly. The objective of this analysis was to compare mortality and other clinical outcomes of trauma patients stratified specifically by injury mechanism and resuscitation strategy. Methods:We performed a retrospective review of the PROPPR trial to assess for differences in mortality outcomes in patients with blunt or penetrating injuries who received a 1:1:1 or 1:1:2 resuscitation strategy. Our primary outcome was 24-hour mortality with additional endpoints at proximate (ie, 1 hour, 3 hours, and 6 hours) times post-arrival. A logistic regression model utilizing general estimating equations and adjusted for age, Injury Severity Score (ISS), and first documented pulse and Glasgow Coma Scale (GCS) score were used to assess the interaction of mortality outcomes by resuscitation type and injury mechanism. Secondary outcomes evaluated include acute kidney injury, ventilator-associated pneumonia, cardiac arrest, symptomatic and asymptomatic pulmonary embolism, deep vein thrombosis, acute respiratory distress syndrome, and stroke. Additional nonmortality outcomes of interest included total hospital and ventilator- and ICU-free days, time to hemostasis, time to exsanguination, and time to death. Results:The original trial enrolled 680 patients, 338 (49.7%) received 1:1:1 and 342 (50.3%) 1:1:2 resuscitation. 8 patients had combined blunt and penetrating injuries and were excluded from this analysis, leaving 672 patients with blunt (350, 52.1%) and penetrating (322, 47.9%) injuries. Compared to penetrating injuries, patients with blunt injuries were older, more likely to be white, had a higher rate of air transfers, longer transport time and longer time to hemostasis, lower GCS Score, and higher ISS and R time on thromboelastography (P < 0.001). Overall mortality between blunt and penetrating injuries was similar at 1 hour (2.6% vs 4.0%, P = 0.286) and 3 hours (7.4% and 8.1%, P = 0.754). However, mortality in both groups steadily increased overtime, and more markedly at 24 hours for patients with blunt compared to penetrating injuries (16.9% and 11.8%, P = 0.063). When comparing resuscitation strategies, receipt of a 1:1:1 resuscitation significantly decreased the odds of mortality among blunt-injured patients who received a 1:1:1 transfusion (relative to blunt-injured patients receiving a 1:1:2 transfusion) at 3 hours (odds ratio [OR]: 0.26, 95% confidence interval [CI]: 0.10-0.66, P = 0.005) and 6 hours (OR: 0.38, 95% CI: 0.19-0.77, P = 0.0007). We observed no statistically significant differences in patients with penetrating injuries or at any time other points. Conclusions:We found a significant difference in adjusted mortality at 3 hours in patients with blunt injuries when comparing resuscitation strategies, which was consistent with previous studies. Responses to resuscitation may differ depending on the mechanism of injury, and some interventions may be more beneficial depending on injury type.