Association of Whole Blood Transfusion With Survival Among Patients Achieving ROSC After Prehospital Traumatic Cardiac Arrest.

Abstract

While whole blood (WB) is increasingly utilized to mitigate trauma-induced coagulopathy, evidence supporting its use in blunt trauma-associated prehospital cardiac arrest (PHCA) remains scarce. We compared the association of WB versus component therapy (CT) with mortality and early resuscitation balance among patients who achieved return of spontaneous circulation (ROSC). This retrospective cohort study used National Trauma Data Bank data from 2020 through 2024. Adults aged 16 years or older with blunt trauma, documented PHCA, a nonzero initial emergency department systolic blood pressure, survival beyond 1 hour after arrival, and receipt of at least 1 unit of WB or red blood cells within 4 hours were included. Propensity score overlap weighting balanced measured baseline characteristics. A prespecified 2-h landmark sensitivity analysis evaluated robustness among early survivors, and restricted cubic spline interaction models assessed heterogeneity across Injury Severity Score (ISS). Among 3472 patients, 995 (28.7%) received WB. Unadjusted 30-day in-hospital mortality was 69.9% with WB and 72.6% with component therapy; weighted estimated mortality was 69.7% and 72.2%, respectively (hazard ratio, 0.89; 95% CI, 0.81-0.97; p = 0.01). Findings were similar in the 2-h landmark analysis (hazard ratio, 0.88; 95% CI, 0.80-0.98; p = 0.02). At similar total transfusion volumes, WB transfusion delivered greater calculated platelet (mean ratio, 1.40; 95% CI, 1.27-1.55) and plasma equivalents (mean ratio, 1.21; 95% CI, 1.10-1.33); 55.4% of component-therapy recipients received no platelets within 4 hours. The association with lower mortality was more pronounced at higher ISS values (interaction p = 0.006). Among selected early survivors of blunt traumatic PHCA with restored circulation during initial hospital assessment, WB transfusion was associated with lower 30-day in-hospital mortality and greater calculated plasma and platelet delivery than component-only therapy. Residual confounding and survivor selection remain possible, and prospective confirmation is needed.