Predictors of Massive Transfusion Protocol Initiation Among Trauma Patients Transported From the Scene Via Flight Emergency Management Services

Published:December 22, 2022DOI:


      • Prehospital prediction of massive transfusion reduces delays in resuscitation.
      • Many factors reported to predict a massive transfusion protocol (MTP) are not available during flight transport.
      • In this study, whole blood, systolic blood pressure, and Glasgow Coma Scale score accurately predicted MTP in trauma patients.
      • Three factors available during flight are of clinical utility in MTP prediction.



      Early identification of the subset of trauma patients with acute hemorrhage who require resuscitation via massive transfusion protocol (MTP) initiation is vital because such identification can ensure the availability of resuscitation products immediately upon hospital arrival and result in improved clinical outcomes, including reduced mortality. However, there are currently few studies on the predictors of MTP in the unique setting of flight transport.


      This was a retrospective study of adult trauma patients transported from the scene via flight to 6 trauma centers between March 1, 2019, and January 21, 2021. Patients were included if they had emergency medical service vitals documented. The variables collected included demographics, comorbidities, cause of injury, body regions injured, in-flight treatments, and transport vitals. The primary outcome was MTP initiated by the receiving hospital.


      A total of 212 patients were included, of whom 16 (8%) had MTP initiated. During flight transport, 24 (11%) received whole blood, 9 (4%) received packed red blood cells, 11 (5%) had a tourniquet placed, and 5 (2%) received tranexamic acid. In adjusted analyses, receiving whole blood during transport (odds ratio [OR] = 8.52, P < .01), systolic blood pressure ≤ 90 mm Hg (OR = 8.07, P < .01), and a Glasgow Coma Scale score < 13 (OR = 8.38, P < .01) were independently associated with MTP.


      This retrospective cohort study showed that 3 factors readily available in the flight setting—receipt of whole blood, systolic blood pressure, and Glasgow Coma Scale score—are strong predictors of MTP at the receiving facility, particularly when considered in aggregate.
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      1. American College of Surgeons. ACS TQIP massive transfusion in trauma guidelines. Available at: Accessed April 13, 2022.

        • Powell EK
        • Hinckley WR
        • Gottula A
        • Hart KW
        • Lindsell CJ
        • McMullan JT.
        Shorter times to packed red blood cell transfusion are associated with decreased risk of death in traumatically injured patients.
        J Trauma Acute Care Surg. 2016; 81: 458-462
        • Meneses E
        • Boneva D
        • McKenney M
        • Elkbuli A.
        Massive transfusion protocol in adult trauma population.
        Am J Emerg Med. 2020; 38: 2661-2666
        • Schroll R
        • Swift D
        • Tatum D
        • et al.
        Accuracy of shock index versus ABC score to predict need for massive transfusion in trauma patients.
        Injury. 2018; 49: 15-19
        • Wu SC
        • Rau CS
        • Kuo SCH
        • Hsu SY
        • Hsieh HY
        • Hsieh CH.
        Shock index increase from the field to the emergency room is associated with higher odds of massive transfusion in trauma patients with stable blood pressure: a cross-sectional analysis.
        PLoS One. 2019; 14e0216153
        • Motameni AT
        • Hodge RA
        • McKinley WI
        • et al.
        The use of ABC score in activation of massive transfusion: the yin and the yang.
        J Trauma Acute Care Surg. 2018; 85: 298-302
        • Nunez TC
        • Voskresensky IV
        • Dossett LA
        • Shinall R
        • Dutton WD
        • Cotton BA.
        Early prediction of massive transfusion in trauma: simple as ABC (Assessment of Blood Consumption)?.
        J Trauma Acute Care Surg. 2009; 66: 346-352
        • Cotton BA
        • Dossett LA
        • Haut ER
        • et al.
        Multicenter validation of a simplified score to predict massive transfusion in trauma.
        J Trauma Acute Care Surg. 2010; 69: S33
        • El-Menyar A
        • Mekkodathil A
        • Abdelrahman H
        • et al.
        Review of existing scoring systems for massive blood transfusion in trauma patients: where do we stand?.
        Shock. 2019; 52: 288-299
        • Callcut RA
        • Cripps MW
        • Nelson MF
        • Conroy AS
        • Robinson BBR
        • Cohen MJ.
        The massive transfusion score as a decision aid for resuscitation: learning when to turn the massive transfusion protocol on and off.
        J Trauma Acute Care Surg. 2016; 80: 450-456
        • Chaochankit W
        • Akaraborworn O
        • Sangthong B
        • Thongkhao K.
        Combination of blood lactate level with assessment of blood consumption (ABC) scoring system: a more accurate predictor of massive transfusion requirement.
        Chin J Traumatol. 2018; 21: 96-99
        • Phillips R
        • Acker SN
        • Shahi N
        • et al.
        The ABC-D score improves the sensitivity in predicting need for massive transfusion in pediatric trauma patients.
        J Pediatr Surg. 2020; 55: 331-334
        • Lee YT
        • Bae BK
        • Cho YM
        • et al.
        Reverse shock index multiplied by Glasgow coma scale as a predictor of massive transfusion in trauma.
        Am J Emerg Med. 2021; 46: 404-409
        • Krook C
        • O'Dochartaigh D
        • Martin D
        • et al.
        Blood on board: the development of a prehospital blood transfusion program in a Canadian helicopter emergency medical service.
        CJEM. 2019; 21: 365-373
        • Floccare DJ
        • Stuhlmiller DFE
        • Braithwaite SA
        • et al.
        Appropriate and safe utilization of helicopter emergency medical services: a joint position statement with resource document.
        Prehosp Emerg Care. 2013; 17: 521-525
        • Brown JB
        • Gestring ML
        • Guyette FX
        • et al.
        Helicopter transport improves survival following injury in the absence of a time-saving advantage.
        Surgery. 2016; 159: 947-959
        • Andruszkow H
        • Lefering R
        • Frink M
        • et al.
        Survival benefit of helicopter emergency medical services compared to ground emergency medical services in traumatized patients.
        Crit Care. 2013; 17: R124
        • Manoochehry S
        • Vafabin M
        • Bitaraf S
        • Amiri A.
        A comparison between the ability of Revised Trauma Score and Kampala Trauma Score in predicting mortality; a meta-analysis.
        Arch Acad Emerg Med. 2019; 7: e6
        • Gilpin DA
        • Nelson PG.
        Revised trauma score: a triage tool in the accident and emergency department.
        Injury. 1991; 22: 35-37
        • Kondo Y
        • Abe T
        • Kohshi K
        • Tokuda Y
        • Cook EF
        • Kukita I.
        Revised trauma scoring system to predict in-hospital mortality in the emergency department: Glasgow Coma Scale, age, and systolic blood pressure score.
        Crit Care. 2011; 15: R191