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Hemorrhagic Shock

Date Last Search Run: Apr 18, 2021
Table last updated: Jun 26, 2021
Data last added: Jul 29, 2021

Recommendation RECOMMENDATION FOR INTERVENTION
STRENGTH OF EVIDENCE FOR INTERVENTION   SUPPORTIVE (Green) NEUTRAL (Yellow) AGAINST (Red) NOT YET GRADED (White)
1 (strong evidence exists)  
2 (fair evidence exists)
3 (weak evidence exists)    


Interventions

Aggressive Crystalloids
Level Direction Primary Outcome Patient/Process Setting Reference
I Neutral (Yellow) Mortality Patient PH-Paramedic Dretzke J., Sandercock J., Bayliss S., Burls A. Clinical effectiveness and cost-effectiveness of prehospital IV fluids in trauma patients. Health Technology Assessment 2004; 8:23. Medline
I Opposes (Red) Survival Patient ED-MD Bickell WH., Wall MJ., Pepe PE., et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. New Eng J Med 1994; 331(17):1105-9. Medline
I Opposes (Red) Mortality Patient PH-Paramedic Schreiber MA., Meier EN., Tisherman SA., et al. A controlled resuscitation strategy is feasible and safe in hypotensive trauma patients: Results of a prospective randomized pilot trial. J Trauma Acute Care Surg 2015; 78(4):687-95; discussion 695-7. Medline
II Neutral (Yellow) Survival to discharge Patient PH-Paramedic Dula D., Wood C., Rejmer A., Starr M., Leicht M. Use of prehospital Fluids in Hypotensive Blunt Trauma Patients. Prehospital Emergency Care 2002; 6(4):417-20. Medline
II Neutral (Yellow) Survival Patient PH-Paramedic Kaweski SM., Sise MJ., Virgilio RW. The effect of prehospital fluids on survival in trauma patients. J Trauma 1990; 30:1215-9. Medline
II Neutral (Yellow) Safety Patient PH-Paramedic Leenen M., Scholz A., Lefering R., Flohe S., TraumaRegister DGU . Limited volume resuscitation in hypotensive elderly multiple trauma is safe and prevents early clinical dilutive coagulopathy -- a matched-pair analysis from TraumaRegister DGU((R)). Injury 2014; 45 Suppl 3:S59-63. Medline
II Neutral (Yellow) Survival Patient PH-Paramedic Stiell IG., et al. The OPALS Major Trauma Study: impact of advanced life-support on survival and morbidity. CMAJ 2008; 178:1141-52. Medline
II Neutral (Yellow) Pulmonary artery pressure, Central venous pressure Process ED-MD Wu JJ., Huang MS., Tang GJ., Kao WF., Shih HC., Su CH., et al. Hemodynamic response of modified fluid gelatin compared with lactated ringer's solution for volume expansion in emergency resuscitation of hypovolemic shock patients: preliminary report of a prospective, randomized trial. World J Surg 2001; 25(5):598-602. Medline
II Neutral (Yellow) Mortality and use of PRBCs. Patient ED-Paramedic & MD Zitek T, Ataya R, Farino L, Mohammed S, Miller G. Is the use of greater than 1 L of intravenous crystalloids associated with worse outcomes in trauma patients? Am J Emerg Med 2021; 40:32-6. Medline
II Opposes (Red) Mortality Patient PH-Paramedic Brown JB., Cohen MJ., Minei JP., Maier RV., West MA., Billiar TR., et al. Goal-directed resuscitation in the prehospital setting: a propensity-adjusted analysis. J Trauma Acute Care Surg 2013; 74(5):1207-12; discussion 1212-4.
II Opposes (Red) Mortality Patient ED-MD Harada MY., Ko A., Barmparas G., et al. 10-year trend in crystalloid resuscitation: Reduced volume and lower mortality. International journal of surgery (London, England). 2017;38:78-82. Medline
II Opposes (Red) Coagulopathy Patient PH-Paramedic Hubetamann B., Lefering R., Taeger G., Waydhas C., Ruchholtz S., Sven Lendemans and the DGU Trauma Registry. Influence of prehospital fluid resuscitation on patients with multiple injuries in hemorrhagic shock in patients from the DGU trauma registry. J Emerg Trauma Shock 2011; 4(4):465-71. Medline
II Opposes (Red) Mortality Patient PH-Paramedic Hussmann B., Heuer M., Lefering R., et al. Prehospital volume therapy as an independent risk factor after trauma. Biomed Res Int 2015; 354367. Medline
II Opposes (Red) In-hospital mortality Patient Jones DG, Nantais J, Rezende-Neto JB, Yazdani S, Vegas P, Rizoli S. Crystalloid resuscitation in trauma patients: deleterious effect of 5L or more in the first 24h. BMC surgery 2018; 18(1):93. Medline
II Opposes (Red) In-hospital mortality Patient In-Patient Jones DG, Nantais J, Rezende-Neto JB, Yazdani S, Vegas P, Rizoli S. Crystalloid resuscitation in trauma patients: deleterious effect of 5L or more in the first 24h. BMC surgery 2018; 18(1):93. Medline
II Opposes (Red) Mortality Patient ED-MD Ley EJ., Clond MA., Srour MK., et al. Emergency department crystalloid resuscitation of 1.5 L or more is associated with increased mortality in elderly and nonelderly trauma patients. J Trauma 2011; 70(2):398-400. Medline
II Opposes (Red) Multi-organ failure rate Patient PH-Paramedic Regel G., Stalp M., Lehmann U., Seekamp A. Prehospital care, importance of early intervention on outcome. Acta Anaesthesiol Scand Suppl 1997; 110:71-6. Medline
II Opposes (Red) Identification of coagulopathy risk factors Patient Wafaisade A., Wutzler S., Lefering R., et al. Drivers of acute coagulopathy after severe trauma: A multivariate analysis of 1987 patients. Emerg Med J 2010; 27(12):934-939. Medline
III Supportive (Green) Mortality Patient PH-Paramedic Sanson G., Di Bartolomeo S., Nardi G., et al. Road traffic accident with vehicular entrapment: incidence of major injuries and need for advanced life support. Eur J Emerg Med 1999; 6(4):285-91. Medline
III Supportive (Green) Mortality Patient ED-MD Velanovich V. Crystalloid versus colloid fluid resuscitation: A meta-analysis of mortality. Surgery 1989; 105:65-71. Medline
III Neutral (Yellow) Volume infused Process PH-Paramedic Dalton MA. Prehospital intravenous fluid replacement in trauma: An outmoded concept. J R Soc Med 1995; 88:213-6. Medline
III Neutral (Yellow) correct performance of intervention Patient PH-Paramedic Lairet JR., Bebarta VS., Burns CJ., Lairet KF., Rasmussen TE., Renz EM., et al. Prehospital interventions performed in a combat zone: a prospective multicenter study of 1,003 combat wounded. J Trauma Acute Care Surg 2012; 73(2S1):S38-42. Medline
III Neutral (Yellow) correct performance of intervention Patient PH-Paramedic Lairet JR., Bebarta VS., Burns CJ., Lairet KF., Rasmussen TE., Renz EM., et al. Prehospital interventions performed in a combat zone: a prospective multicenter study of 1,003 combat wounded. J Trauma Acute Care Surg 2012; 73(2S1):S38-42. Medline
III Neutral (Yellow) Predicted survival Patient SIM Wears RL., Winton CN. Load and go versus stay and play: analysis of prehospital i.v. fluid therapy by computer simulation. Ann Emerg Med 1990; 19(2):163-168. Medline
III Opposes (Red) One hour survival Patient Kowalenko T., Stern S., Dronen S., et al. Improved outcome with hypotensive resuscitation of uncontrolled hemorrhagic shock in a swine model. Jtrauma 1992; 33:349353. Medline
III Opposes (Red) Mean arterial pressure Patient Krausz MM., Bar-Ziv M., Rabinovici R., et al. Scoop and run or stabilize hemorragic shock with normal saline or small-volume hypertonic saline. J of Trauma 1992; 33:6-10. Medline

Blood transfusion
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) 24 hr. survival from severe trauma Patient Other Brown JBB, Sperry JL, Fombona A, Billiar TR, Peitzman AB, Guyette FX. Pre-Trauma Center Red Blood Cell Transfusion Is Associated with Improved Early Outcomes in Air Medical Trauma Patients. Journal of the American College of Surgeons 2015; 220(5):797-808. Medline
II Supportive (Green) Characteristics of patient's receiving prehospital PRBC Patient Lyon RM., de Sausmarez E., McWhirter E., et al. Pre-hospital transfusion of packed red blood cells in 147 patients from a UK helicopter emergency medical service. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2017; 25(1):12. Medline
II Supportive (Green) Hemodynamic stability Patient PH-Paramedic & CCT Parker ME., Khasawneh MA., Thiels CA., Berns KS., Stubbs JR., Jenkins DH., et al. Prehospital Transfusion for Gastrointestinal Bleeding. Air Med J; 36(6) 315-9. Medline
II Supportive (Green) 24 hour and 30 day survival Patient PH-Paramedic & MD Shackelford SA., Del JD, Powell-Dunford N., Mazuchowski EL., Howard JT., Kotwal RS., et al. Association of Prehospital Blood Product Transfusion During Medical Evacuation of Combat Casualties in Afghanistan With Acute and 30-Day Survival. JAMA 2017; 318(16) 1581-91. Medline
II Neutral (Yellow) Feasibility Patient PH-Paramedic & MD Bodnar D, Rashford S, Hurn C, Quinn J, Parker L, Isoardi K, Williams S. Characteristics and outcomes of patients administered blood in the prehospital environment by a road based trauma response team. Emerg Med J 2014; 31:583–8. Medline
II Neutral (Yellow) Patient centered mortality Process ED-Paramedic & MD Brinck T., Handolin L., Lefering R. The effect of evolving fluid resuscitation on the outcome of severely injured patients: An 8-year experience at a tertiary trauma center. Scandinavian journal of surgery : SJS : official organ for the Finnish Surgical Society and the Scandinavian Surgical Society. 2016;105(2):109-16. Medline
II Neutral (Yellow) All cause mortality at 6 h Patient PH-Paramedic & MD Griggs JE., Jeyanathan J., Joy M., Russell MQ., Durge N., Bootland D., et al. Mortality of civilian patients with suspected traumatic haemorrhage receiving pre-hospital transfusion of packed red blood cells compared to pre-hospital crystalloid. Scandinavian journal of trauma, resuscitation and emergency medicine 2018; 26(1) 100. Medline
II Neutral (Yellow) In-hospital mortality Patient In-Patient Haltmeier T, Benjamin E, Gruen JP, Shulman IA, Lam L, Inaba K, et al. Decreased mortality in patients with isolated severe blunt traumatic brain injury receiving higher plasma to packed red blood cells transfusion ratios. Injury 2018; 49(1):62-6. Medline
II Neutral (Yellow) Rapid thromboelastographic (Rteg) Patient PH-Paramedic Henriksen HH., Rahbar E., Baer LA., Holcomb JB., Cotton BA., Steinmetz J., et al. Pre-hospital transfusion of plasma in hemorrhaging trauma patients independently improves hemostatic competence and acidosis. Scand J Trauma Resusc Emerg Med 2016; 24(1):145. Medline
II Neutral (Yellow) TBD Process PH-MD & CCT Heschl S, Andrew E, de WA, Bernard S, Kennedy M, Smith K, et al. Prehospital transfusion of red cell concentrates in a paramedic-staffed helicopter emergency medical service. Emergency medicine Australasia: EMA 2018; 30(2):236-41. Medline
II Neutral (Yellow) 3-hour, 24-hour and 30-day mortality Patient Holcomb JB, Swartz MD, DeSantis SM, Greene TJ, Fox EE, Stein DM, Bulger EM, Kerby JD, Goodman M, Schreiber MA, Zielinski MD, O’Keeffe T, Kenji Inaba K, Tomasek JS, Podbielski JM, Appana SN, Misung Yi M, Wade CE. Multicenter observational prehospital resuscitation on helicopter study. J Trauma Acute Care Surg 2017; 83(1 S1):S83-91. Medline
II Neutral (Yellow) Mortality Patient Other Huang GS, Dunham CM. Mortality outcomes in trauma patients undergoing prehospital red blood cell transfusion: a systematic literature review. International journal of burns and trauma 2017; 7(2):17-26. Medline
II Neutral (Yellow) mortality Process ED-Paramedic & MD O’Reilly DJ, Morrison JJ, Jansen JO, Apodaca AN, Rasmussen TE, Midwinter MJ. Prehospital blood transfusion in the en route management of severe combat trauma: A matched cohort study. J Trauma Acute Care Surg 2014; 77(3S2):S114-20. Medline
II Neutral (Yellow) 24 hour survival Patient Peters JH, Smulders PSH, Moors XRJ, Bouman SJM, Meijs CMEM, Hoogerwerf N, et al. Are on-scene blood transfusions by a helicopter emergency medical service useful and safe? A multicentre case-control study. European journal of emergency medicine: official journal of the European Society for Emergency Medicine 2017. Medline
II Neutral (Yellow) Mortality Patient Rehn M, Weaver A, Brohi K, Eshelby S, Green L, Røislien J, et al. Effect of Pre-Hospital Red Blood Cell Transfusion on Mortality and Time of Death in Civilian Trauma Patients. Shock (Augusta, Ga) 2018. Medline
II Neutral (Yellow) Appropriate use Process PH-Paramedic & CCT Thiels CA, Aho JM, Fahy AS, Parker ME, Glasgow AE, Berns KS, Habermann EB, Zietlow SP, Zielinski MD. Prehospital Blood Transfusions in Non-Trauma Patients. World J Surg 2016; 40:2297–304. Medline
II Neutral (Yellow) Patient hypothermia Patient PH-Paramedic & CCT Wheeler R, von Recklinghausen FM, Brozen R. Blood Administration in Helicopter Emergency Medical Services Patients Associated With Hypothermia. Air Medical Journal 2013; 32(1): 47-51. Medline
III Supportive (Green) Additional transfusion of blood at hospital Patient PH-Paramedic & MD Barkana, Y, Stein M, Maor R, Lynn M, Eldad A. Prehospital Blood Transfusion in Prolonged Evacuation. The Journal of Trauma: Injury, Infection, and Critical Care 1999; 46(1):176-80. Medline
III Supportive (Green) Safe administration Process PH-Paramedic & CCT LTC Robert F. Malsby III, MAJ Jose Quesada, MAJ Nicole Powell-Dunford, CPT Ren Kinoshita, CPT John Kurtz, CPT William Gehlen, CPT Colleen Adams, MAJ Dustin Martin, Col Stacy Shackelford. Prehospital Blood Product Transfusion by U.S. Army MEDEVAC During Combat Operations in Afghanistan: A Process Improvement Initiative. MILITARY MEDICINE 2013; 178(7):785-91. Medline
III Supportive (Green) Appropriate use of blood product Process PH-MD & CCT Raitt JE, Norris-Cervetto E, Hawksley O. A report of two years of pre-hospital blood transfusions by Thames Valley Air Ambulance. Trauma 2018; 20(3):221–4. Medline
III Supportive (Green) In-hospital use of platelets and FFP in the first 24h and total Process PH-MD & CCT Rehn M., Weaver AE., Eshelby S., Rislien J., Lockey DJ. Pre-hospital transfusion of red blood cells in civilian trauma patients. Transfus Med 2017. Medline
III Neutral (Yellow) Feasibility Patient PH-Paramedic & CCT Mix F, Zielinski M, Myers L, Berns K, Luke A, Stubbs J, Sztajnkrycer M. Prehospital Blood Product Administration Opportunities in Ground Transport ALS EMS – A Descriptive Study. Prehospital and Disaster Medicine 2018, 33(3):230-6. Medline
III Neutral (Yellow) Feasibility Patient Sunde GA., Vikenes B., Strandenes G., et al. Freeze dried plasma and fresh red blood cells for civilian prehospital hemorrhagic shock resuscitation. J Trauma Acute Care Surg 2015; 78(6 Suppl 1):S26-30. Medline
X Not Yet Graded (White) - Ångerman S, Kirves H, Nurmi J. Characteristics of Nontrauma Patients Receiving Prehospital Blood Transfusion with the Same Triggers as Trauma Patients: A Retrospective Observational Cohort Study. Prehosp Emerg Care 2021:1-9. Medline
X Not Yet Graded (White) - Guyette FX, Sperry JL, Peitzman AB, Billiar TR, Daley BJ, Miller RS, et al. Prehospital Blood Product and Crystalloid Resuscitation in the Severely Injured Patient: A Secondary Analysis of the Prehospital Air Medical Plasma Trial. Ann Surg 2021; 273(2):358-64. Medline
X Not Yet Graded (White) - Mikati N, Phillips AR, Corbelli N, Guyette FX, Liang NL. The Effect of Blood Transfusion during Air Medical Transport on Transport Times in Patients with Ruptured Abdominal Aortic Aneurysm. Prehosp Emerg Care 2021:1-8. Medline

Colloid Infusion
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Base excess Patient Masoumi K., Forouzan A., Darian AA., Rafaty Navaii A. Comparison of the Effectiveness of Hydroxyethyl Starch (Voluven) Solution With Normal Saline in Hemorrhagic Shock Treatment in Trauma. J Clin Med Res 2016; 8(11):815-8. Medline
I Neutral (Yellow) Mortality Patient PH-Paramedic Dretzke J., Sandercock J., Bayliss S., Burls A. Clinical effectiveness and cost-effectiveness of prehospital IV fluids in trauma patients. Health Technology Assessment 2004; 8:23. Medline
I Neutral (Yellow) Mortality Patient ICU Lewis SR, Pritchard MW, Evans DJ, Butler AR, Alderson P, Smith AF, et al. Colloids versus crystalloids for fluid resuscitation in critically ill people. The Cochrane database of systematic reviews 2018; 8. Medline
II Supportive (Green) Successful resuscitation Patient ED-MD Nagy KK., Davis J., Duda J., et al. A comparison of pentastarch and lactated ringer's solution in the resuscitation of patients with hemorrhagic shock. Circulatory Shock 1993; 40:289-94. Medline
II Supportive (Green) Pulmonary artery pressure, Central venous pressure Process ED-MD Wu JJ., Huang MS., Tang GJ., Kao WF., Shih HC., Su CH., et al. Hemodynamic response of modified fluid gelatin compared with lactated ringer's solution for volume expansion in emergency resuscitation of hypovolemic shock patients: preliminary report of a prospective, randomized trial. World J Surg 2001; 25(5):598-602. Medline
III Supportive (Green) Mortality Patient ED-MD Velanovich V. Crystalloid versus colloid fluid resuscitation: A meta-analysis of mortality. Surgery 1989; 105:65-71. Medline
III Opposes (Red) Mean arterial pressure Patient Krausz MM., Bar-Ziv M., Rabinovici R., et al. Scoop and run or stabilize hemorragic shock with normal saline or small-volume hypertonic saline. J of Trauma 1992; 33:6-10. Medline
X Not Yet Graded (White) - Patient Younes RN., Yin KC., Amino CJ., Itinoshe M., Rocha e Silva M., Birolini D. Use of pentastarch solution in the treatment of patients with hemorrhagic hypovolemia: randomized phase II study in the emergency room. World J Surg 1998; 22(1):2-5. Medline

Fibrinogen concentrate
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Clot stability. Patient ED-Paramedic & MD Ziegler B, Bachler M, Haberfellner H, Niederwanger C, Innerhofer P, Hell T, et al. Efficacy of prehospital administration of fibrinogen concentrate in trauma patients bleeding or presumed to bleed (FIinTIC): A multicentre, double-blind, placebo-controlled, randomised pilot study. Eur J Anaesthesiol 2020 Medline

Hypertonic Saline
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Improvement in hemodynamics Patient Ghafari MH., Moosavizadeh SA., Moharari RS., Khashayar P. Hypertonic saline 5% vs. lactated ringer for resuscitating patients in hemorrhagic shock. Middle East J Anesthesiol 2008; 19(6):1337-47. Medline
I Neutral (Yellow) Survival to hospital discharge Patient PH-Paramedic Blanchard IE, Ahmad A, Tang KL, Ronksley PE, Lorenzetti D, Lazarenko G, et al. The effectiveness of prehospital hypertonic saline for hypotensive trauma patients: a systematic review and meta-analysis. BMC emergency medicine 2017; 17(1):35. Medline
I Neutral (Yellow) 28-day mortality Patient PH-Paramedic Bulger EM., et al. Out-Of-Hospital Hypertonic Resuscitation After Traumatic Hypovolemic Shock. Ann Surg 2011; 253(3):431-41. Medline
I Neutral (Yellow) Survival Patient ED-MD Vassar MJ., Perry CA., Holcroft JW. Prehospital resuscitation of hypotensive trauma patients with 7.5% NaCl versus 7.5% NaCl with added dextran: a controlled trial. J Trauma 1993; 34(5):622-32; discussion 632-3. Medline
I Neutral (Yellow) Survival Patient ED-MD Wu MC, Liao TY, Lee EM, Chen YS, Hsu WT, Lee MG, et al. Administration of Hypertonic Solutions for Hemorrhagic Shock: A Systematic Review and Meta-analysis of Clinical Trials. Anesth Analg 2017; 125(5):1549-57. Medline
II Supportive (Green) Hemodynamic parameters, volume expansion Process ED-MD Younes RN., Aun F., Accioly CQ., Casale LP., Szajnbok I., Birolini D. Hypertonic solutions in the treatment of hypovolemic shock: a prospective, randomized study in patients admitted to the emergency room. Surgery 1992; 111(4):380-385. Medline
II Neutral (Yellow) Homeostatic lab values Patient ED-MD Mauritz W., Schimetta W., Oberreither S., Polz W. Are hypertonic hyperoncotic solutions safe for prehospital small-volume resuscitation? Results of a prospective observational study. Eur J Emerg Med 2002; 9(4):315-9. Medline
III Supportive (Green) Feasibility Process PH-Paramedic Maningas P., Mattox K., Pepe P., et al. Hypertonic saline-dextran solutions for the prehospital management of traumatic hypotension. The American J Surgery 1989; 157:528-34. Medline
III Supportive (Green) Improved cardiac work and oxygen consumption Patient Siritongtaworn P., Moore EE., Marx JA., et al. The benefits of 7.5% NaCl/6% dextran 70 (HSD) for prehospital resuscitation of hemorrhagic shock: Improved oxygen transport. Brazilian J Med Biol Res 1989; 22:275-278. Medline
III Supportive (Green) Risk Patient ED-MD Vasser MJ., Perry CA., Holcroft JW. Analysis of potential risks associated with 7.5% sodium chloride resuscitation of traumatic shock. Arch Surg 1990; 125:1309-1315. Medline
III Neutral (Yellow) Survival Patient PH-Paramedic Mattox K., Maningas P., Moore E., et al. Prehospital hypertonic saline/dextran infusion for post-traumatic hypotension. Ann Surg 1991; 213:482-91. Medline
III Neutral (Yellow) Predictors of response to hypertonic saline Process ED-MD Younes RN., Chan FA., Ching CT., et al. Prognastic factors to predict outcome following the administration of hypertonic solution in hypovolemic patients. Shock 1997; 7:79-83. Medline
III Opposes (Red) Mean arterial pressure Patient Krausz MM., Bar-Ziv M., Rabinovici R., et al. Scoop and run or stabilize hemorragic shock with normal saline or small-volume hypertonic saline. J of Trauma 1992; 33:6-10. Medline

Manual Intraosseous Insertion
Level Direction Primary Outcome Patient/Process Setting Reference
II Neutral (Yellow) Insertion success rate Process PH-Paramedic Frascone RJ., Jensen JP., Kaye K., Salzman JG. Consecutive field trials using two different IO devices. Prehosp Emer Care 2007; 11:164-71. Medline
II Neutral (Yellow) First attempt success Patient Sunde G., Heradstveit B., Vikenes B., HeltneJ. Emergency intraosseous access in a helicopter emergency medical service: a retrospective study. Scan J Trauma, Resus and Emerg Med 2010; 18:52. Medline
III Supportive (Green) First attempt success Process ED-MD Leidel BA., Kirchhoff C., Bogner V., Braunstein V., Biberthaler P., Kanz KG. Comparison of intraosseous versus central venous vascular access in adults under resuscitation in the emergency department with inaccessible peripheral veins. Resuscitation 2012; 83(1):40-5. Medline
III Supportive (Green) Success Patient ED-MD Voigt J., Waltzman M., Lottenberg L. Intraosseous vascular access for in-hospital emergency use: A systematic clinical review of the literature and analysis. Pediatr Emerg Care 2012; 28(2):185-199. Medline
III Neutral (Yellow) Complications Patient ED-MD Brenner T., Bernhard M., Helm M., Doll S., Völkl A., Ganion N., Friedmann C., Sikinger M., Knapp J., Martin E., Gries A. Comparison of two intraosseous infusion systems for adult emergency medical use. Resuscitation 2008; 78:314-9. Medline

MAST
Level Direction Primary Outcome Patient/Process Setting Reference
I Neutral (Yellow) Survival Patient PH-Paramedic Bickell WH., Pepe PE., Bailey ML., et al. Randomized trial of pneumatic antishock garments in the prehospital management of penetrating abdominal injuries. Ann Emerg Med 1987; 16(6):79-84. Medline
I Opposes (Red) Survival Patient PH-Paramedic Mattox KL., Bickell W., Pepe PE., et al. Prospective MAST study in 911 patients. J of Trauma 1989; 29:1104-12. Medline
III Supportive (Green) blood pressure before and after application of MAST Patient PH-Paramedic Kaplan BC., Civetta JM., Nagel EL., Nussenfeld SR., Hirschman JC. The military anti-shock trouser in civilian pre-hospital emergency care. J Trauma 1973; 13(10):843-8. Medline
III Neutral (Yellow) Control of hemorrhage, survival, cause of death Process Bruining HA., Schattienkerk EM., De Vries JE., et al. Clinical experience with the medical anti-shock trousers(MAST) in the treatment of hemorrhage, especially from compound pelvic fracture. Netherlands J of Surgery 1980; 32:102-7. Medline
III Neutral (Yellow) Length of hospital stay Patient PH-Paramedic Mattox KL., Bickell WH., Pepe PE., at al. Prospective randomized evaluation of antishock MAST in post-traumatic hypotension. J Trauma 1986; 26(9):779-86. Medline

Mechanical Intraosseous Insertion
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Number of attempts required Process SIM Brenner T., Bernhard M., Helm M., Doll S., Völkl A., Ganion N., Friedmann C., Sikinger M., Knapp J., Martin E., Gries A. Comparison of two intraosseous infusion systems for adult emergency medical use. Resuscitation 2008; 78:314-9. Medline
II Supportive (Green) Successful placement Process Dolister M., Miller S., Borron S., et al. Intraosseous vascular access is safe, effective and cost less than central venous catheters for patients in the hospital setting. J Vasc Access 2013; 14(3):216-24. Medline
II Supportive (Green) First attempt success Patient Sunde G., Heradstveit B., Vikenes B., HeltneJ. Emergency intraosseous access in a helicopter emergency medical service: a retrospective study. Scan J Trauma, Resus and Emerg Med 2010; 18:52. Medline
II Neutral (Yellow) Insertion success rate Process PH-Paramedic Frascone RJ., Jensen JP., Kaye K., Salzman JG. Consecutive field trials using two different IO devices. Prehosp Emer Care 2007; 11:164-71. Medline
III Supportive (Green) Time (seconds) for successful access Process Lamhaut L., Dagron C., Apriotesei R., et al. Comparison of intravenous and intraosseous access by pre-hospital medical emergency personnel with and without CBRN protective equipment. Resuscitation 2010; 81(1):65-68. Medline
III Supportive (Green) Successful insertion Process Levitan RM., Bortle CD., Snyder TA., Nitsch DA., Pisaturo JT., Butler KH. Use of a battery-operated needle driver for intraosseous access by novice users: Skill acquisition with cadavers. Ann Emerg Med 2009; 54(5):692-4. Medline
III Supportive (Green) First attempt success Process SIM Ong ME., Ngo AS., Wijaya R. An observational, prospective study to determine the ease of vascular access in adults using a novel intraosseous access device. Ann Acad Med Singapore 2009; 38:121-4. Medline
III Supportive (Green) Overall placement success Process PH-Paramedic Schalk R., Schweigkofler U., Lotz G., Zacharowski K., Latasch L., Byhahn C. Efficacy of the EZ-IO needle driver for out-of-hospital intraosseous access--a preliminary, observational, multicenter study. Scand J Trauma Resusc Emerg Med 2011; 19:65-7241-19-65. Medline
III Supportive (Green) Success Patient ED-MD Voigt J., Waltzman M., Lottenberg L. Intraosseous vascular access for in-hospital emergency use: A systematic clinical review of the literature and analysis. Pediatr Emerg Care 2012; 28(2):185-199. Medline
III Neutral (Yellow) First attempt success Process ED-MD Leidel BA., Kirchhoff C., Bogner V., Braunstein V., Biberthaler P., Kanz KG. Comparison of intraosseous versus central venous vascular access in adults under resuscitation in the emergency department with inaccessible peripheral veins. Resuscitation 2012; 83(1):40-5. Medline

Plasma infusion
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Mortality at 30 days Patient Sperry J., Guyette F., Brown J., et al. Prehospital Plasma during Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock. N Engl J Med 2018; 379(4):315-326. Medline
II Supportive (Green) 30-day Survival Patient PH-Paramedic & CCT Gruen DS, Guyette FX, Brown JB, Okonkwo DO, Puccio AM, Campwala IK, et al. Association of Prehospital Plasma With Survival in Patients With Traumatic Brain Injury: A Secondary Analysis of the PAMPer Cluster Randomized Clinical Trial. JAMA Network Open 2020; 3(10):e2016869. Medline
II Supportive (Green) Rapid thromboelastographic (Rteg) Patient PH-Paramedic Henriksen HH., Rahbar E., Baer LA., Holcomb JB., Cotton BA., Steinmetz J., et al. Pre-hospital transfusion of plasma in hemorrhaging trauma patients independently improves hemostatic competence and acidosis. Scand J Trauma Resusc Emerg Med 2016; 24(1):145. Medline
II Supportive (Green) Feasibility Process PH-Paramedic & CCT Oakeshott JE., Griggs JE., Wareham GM., Lyon RM. Feasibility of prehospital freeze-dried plasma administration in a UK Helicopter Emergency Medical Service. European journal of emergency medicine 2018. Medline
II Supportive (Green) Mortality Patient PH-Paramedic Shlaifer A, Siman-Tov M, Radomislensky I, Peleg K, Klein Y, Glassberg E, et al. The impact of prehospital administration of freeze-dried plasma on casualty outcome. The journal of trauma and acute care surgery 2019; 86(1):108-15. Medline
II Neutral (Yellow) Mortality (3 hour, 24 hour, 30 day) Patient Holcomb JB, Swartz MD, DeSantis SM, Greene TJ, Fox EE, Stein DM, Bulger EM, Kerby JD, Goodman M, Schreiber MA, Zielinski MD, O’Keeffe T, Kenji Inaba K, Tomasek JS, Podbielski JM, Appana SN, Misung Yi M, Wade CE. Multicenter observational prehospital resuscitation on helicopter study. J Trauma Acute Care Surg 2017; 83(1 S1):S83-91. Medline
III Neutral (Yellow) 28 day mortality Patient PH-Paramedic Moore HB., Moore EE., Chapman MP., McVaney K., Bryskiewicz G., Blechar R., et al. Plasma-first resuscitation to treat haemorrhagic shock during emergency ground transportation in an urban area a randomised trial. Lancet (London, England) 2018; 392(10144) 283-91. Medline
X Not Yet Graded (White) - Guyette FX, Sperry JL, Peitzman AB, Billiar TR, Daley BJ, Miller RS, et al. Prehospital Blood Product and Crystalloid Resuscitation in the Severely Injured Patient: A Secondary Analysis of the Prehospital Air Medical Plasma Trial. Ann Surg 2021; 273(2):358-64. Medline
X Not Yet Graded (White) - Reitz KM, Gruen DS, Guyette F, Brown JB, Yazer MH, Vodovotz Y, et al. Age of thawed plasma does not affect clinical outcomes or biomarker expression in patients receiving prehospital thawed plasma: a PAMPer secondary analysis. Trauma Surg Acute Care Open 2021; 6(1):e000648. Medline

Pressors
Level Direction Primary Outcome Patient/Process Setting Reference
II Opposes (Red) In-hospital mortality Patient In-Patient Aoki M, Abe T, Saitoh D, Hagiwara S, Oshima K. Use of Vasopressor Increases the Risk of Mortality in Traumatic Hemorrhagic Shock: A Nationwide Cohort Study in Japan. Crit Care Med 2018; 46(12):e1145-51. Medline
X Not Yet Graded (White) - Fisher AD, April MD, Cunningham C, Schauer SG. Prehospital Vasopressor Use Is Associated with Worse Mortality in Combat Wounded. Prehosp Emerg Care 2021; 25(2):268-73. Medline

Restricted Crystalloids
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Survival Patient ED-MD Bickell WH., Wall MJ., Pepe PE., et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. New Eng J Med 1994; 331(17):1105-9. Medline
I Supportive (Green) Mortality Patient PH-Paramedic Schreiber MA., Meier EN., Tisherman SA., et al. A controlled resuscitation strategy is feasible and safe in hypotensive trauma patients: Results of a prospective randomized pilot trial. J Trauma Acute Care Surg 2015; 78(4):687-95; discussion 695-7. Medline
I Neutral (Yellow) Mortality Patient PH-Paramedic Dretzke J., Sandercock J., Bayliss S., Burls A. Clinical effectiveness and cost-effectiveness of prehospital IV fluids in trauma patients. Health Technology Assessment 2004; 8:23. Medline
II Supportive (Green) Prevention of status epilepticus Patient ED-MD Brown JB., Cohen MJ., Minei JP., Maier RV., West MA., Billiar TR., et al. Goal-directed resuscitation in the prehospital setting: a propensity-adjusted analysis. J Trauma Acute Care Surg 2013; 74(5):1207-12; discussion 1212-4.
II Supportive (Green) Survival benefit Patient Duke MD., Guidry C., Guice J., et al. Restrictive fluid resuscitation in combination with damage control resuscitation: Time for adaptation. J Trauma Acute Care Surg 2012; 73(3):674-8. Medline
II Supportive (Green) Survival Patient PH-Paramedic Hampton DA., Fabricant LJ., Differding J., Diggs B., Underwood S., De La Cruz D., et al. Prehospital intravenous fluid is associated with increased survival in trauma patients. J Trauma Acute Care Surg 2013; 75(1S1):S9-15. Medline
II Supportive (Green) Mortality Patient Harada MY., Ko A., Barmparas G., et al. 10-year trend in crystalloid resuscitation: Reduced volume and lower mortality. International journal of surgery (London, England). 2017;38:78-82. Medline
II Supportive (Green) Mortality Patient PH-Paramedic Hussmann B., Heuer M., Lefering R., et al. Prehospital volume therapy as an independent risk factor after trauma. Biomed Res Int 2015; 354367. Medline
II Supportive (Green) In-hospital mortality Patient ED-MD Jones DG, Nantais J, Rezende-Neto JB, Yazdani S, Vegas P, Rizoli S. Crystalloid resuscitation in trauma patients: deleterious effect of 5L or more in the first 24h. BMC surgery 2018; 18(1):93. Medline
II Supportive (Green) In-hospital mortality Patient In-Patient Jones DG, Nantais J, Rezende-Neto JB, Yazdani S, Vegas P, Rizoli S. Crystalloid resuscitation in trauma patients: deleterious effect of 5L or more in the first 24h. BMC surgery 2018; 18(1):93. Medline
II Supportive (Green) Multi-organ failure rate Patient PH-Paramedic Regel G., Stalp M., Lehmann U., Seekamp A. Prehospital care, importance of early intervention on outcome. Acta Anaesthesiol Scand Suppl 1997; 110:71-6. Medline
II Supportive (Green) Identification of coagulopathy risk factors Patient Wafaisade A., Wutzler S., Lefering R., et al. Drivers of acute coagulopathy after severe trauma: A multivariate analysis of 1987 patients. Emerg Med J 2010; 27(12):934-939. Medline
II Neutral (Yellow) Coagulopathy Patient PH-Paramedic Hubetamann B., Lefering R., Taeger G., Waydhas C., Ruchholtz S., Sven Lendemans and the DGU Trauma Registry. Influence of prehospital fluid resuscitation on patients with multiple injuries in hemorrhagic shock in patients from the DGU trauma registry. J Emerg Trauma Shock 2011; 4(4):465-71. Medline
II Neutral (Yellow) Mortality Patient PH-Paramedic Hussmann B., Heuer M., Lefering R., et al. Prehospital volume therapy as an independent risk factor after trauma. Biomed Res Int 2015; 354367. Medline
II Neutral (Yellow) Safety Patient PH-Paramedic Leenen M., Scholz A., Lefering R., Flohe S., TraumaRegister DGU . Limited volume resuscitation in hypotensive elderly multiple trauma is safe and prevents early clinical dilutive coagulopathy -- a matched-pair analysis from TraumaRegister DGU((R)). Injury 2014; 45 Suppl 3:S59-63. Medline
III Supportive (Green) Mortality Patient PH-Paramedic & MD Albreiki M, Voegeli D. Permissive hypotensive resuscitation in adult patients with traumatic haemorrhagic shock: a systematic review. European journal of trauma and emergency surgery: official publication of the European Trauma Society 2018; 44(2):191-202. Medline
III Supportive (Green) One hour survival Patient Kowalenko T., Stern S., Dronen S., et al. Improved outcome with hypotensive resuscitation of uncontrolled hemorrhagic shock in a swine model. Jtrauma 1992; 33:349353. Medline
III Supportive (Green) Likelihood of successful defibrillation Process Krausz MM., Bar-Ziv M., Rabinovici R., et al. Scoop and run or stabilize hemorragic shock with normal saline or small-volume hypertonic saline. J of Trauma 1992; 33:6-10. Medline
III Neutral (Yellow) Predicted survival Patient SIM Wears RL., Winton CN. Load and go versus stay and play: analysis of prehospital i.v. fluid therapy by computer simulation. Ann Emerg Med 1990; 19(2):163-168. Medline
X Not Yet Graded (White) - Zitek T, Ataya R, Farino L, Mohammed S, Miller G. Is the use of greater than 1 L of intravenous crystalloids associated with worse outcomes in trauma patients? Am J Emerg Med 2021; 40:32-6. Medline

Shock Prediction Tool
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Accuracy Process PH-Paramedic David JS, Voiglio EJ, Cesareo E, Vassal O, Decullier E, Gueugniaud PY, et al. Prehospital parameters can help to predict coagulopathy and massive transfusion in trauma patients. Vox Sang 2017; 112(6):557-66. Medline
II Supportive (Green) Prediction of transfusion Process ED-MD Frohlich M., Driessen A., Bohmer A., et al. Is the shock index based classification of hypovolemic shock applicable in multiple injured patients with severe traumatic brain injury?-an analysis of the TraumaRegister DGU. Scandinavian journal of trauma, resuscitation and emergency medicine. 2016;24(1):148. Medline
II Supportive (Green) Ability to predict need for transfusion Process Frohlich M., Driessen A., Bohmer A., Nienaber U., Igressa A., Probst C., et al. Is the shock index based classification of hypovolemic shock applicable in multiple injured patients with severe traumatic brain injury?-an analysis of the TraumaRegister DGU®. Scand J Trauma Resusc Emerg Med 2016; 24(1):148. Medline
II Supportive (Green) Need for trauma centre Patient Haider AA., Azim A., Rhee P., et al. Substituting systolic blood pressure with shock index in the national trauma triage protocol. The journal of trauma and acute care surgery 2016; 81(6):1136-1141. Medline
II Supportive (Green) Prediction of in-hospital mortality Process ED-MD Kimura A., Tanaka N. Reverse shock index multiplied by Glasgow Coma Scale score (rSIG) is a simple measure with high discriminant ability for mortality risk in trauma patients an analysis of the Japan Trauma Data Bank. Crit Care 2018; 22(1) 87. Medline
II Supportive (Green) predictor of injury severity Patient Lai WH., Rau CS., Hsu SY., et al. Using the reverse shock index at the injury scene and in the emergency department to identify high-risk patients: A cross-sectional retrospective study. International journal of environmental research and public health. 2016;13(4):357. Medline
II Supportive (Green) Prediction of need for massive transfusion Patient ED-MD Mclennan JV., Mackway-Jones KC., Smith JE. Prediction of massive blood transfusion in battlefield trauma Development and validation of the Military Acute Severe Haemorrhage (MASH) score. Injury 2018; 49(2) 184-90. Medline
II Supportive (Green) Prediction of requirement for massive transfusion protocol activation. Process ED-MD Schroll R, Swift D, Tatum D, Couch S, Heaney JB, Llado-Farrulla M, et al. Accuracy of shock index versus ABC score to predict need for massive transfusion in trauma patients. Injury 2018; 49(1):15-9. Medline
II Supportive (Green) Prediction of need for blood products Patient In-Patient Tonglet M., Lefering R., Minon JM., Ghuysen A., D'Orio V., Hildebrand F., et al. Prehospital identification of trauma patients requiring transfusion results of a retrospective study evaluating the use of the trauma induced coagulopathy clinical score (TICCS) in 33,385 patients from the TraumaRegister DGU®. Acta Chir Belg 2017; 117(6) 385-390. Medline
II Supportive (Green) Predicting need for massive transfusion Process PH-Paramedic Wang IJ., Bae BK., Park SW., Cho YM., Lee DS., Min MK., et al. Pre-hospital modified shock index for prediction of massive transfusion and mortality in trauma patients. Am J Emerg Med 2019. Medline
II Neutral (Yellow) Prediction of requirement for massive transfusion Process Rau CS., Wu SC., Kuo SC., Pao-Jen K., Shiun-Yuan H., Chen YC., et al. Prediction of Massive Transfusion in Trauma Patients with Shock Index, Modified Shock Index, and Age Shock Index. Int J Environ Res Public Health 2016; 13(7):10.3390. Medline
III Supportive (Green) Anticipation of need for massive transfusion Process ED-MD Day DL., Anzelon KM., Conde FA. Association of Prehospital Shock Index and Trauma Bay Uncrossmatched Red Blood Cell Transfusion With Multiple Transfusion. J Trauma Nurs 2016; 23(2):89-95. Medline
III Supportive (Green) predictability of severe hemorrhage Patient PH-Paramedic & MD Hamada SR, Rosa A, Gauss T, Desclefs JP, Raux M, Harrois A, et al. Development and validation of a pre-hospital "Red Flag" alert for activation of intra-hospital haemorrhage control response in blunt trauma. Crit Care 2018; 22(1):113. Medline
III Supportive (Green) Validity Process PH-Paramedic Terceros-Almanza LJ, García-Fuentes C, Bermejo-Aznárez S, Prieto Del PI, Mudarra-Reche C, Domá-nguez-Aguado H, et al. Prediction of massive bleeding in a prehospital setting: validation of six scoring systems. Medicina intensiva 2018. Medline
III Neutral (Yellow) The accuracy of the Shock Index (SI)and pulse pressure/Heart Rate (PP/HR) to predict massive transfusion after severe trauma. Process Pottecher J., Ageron FX., Fauche C., Chemla D., Noll E., Duranteau J., et al. Prehospital shock index and pulse pressure/heart rate ratio to predict massive transfusion after severe trauma: Retrospective analysis of a large regional trauma database. J Trauma Acute Care Surg 2016; 81(4):713-22. Medline
X Not Yet Graded (White) - Peltan ID., Rowhani-Rahbar A., Vande Vusse LK., Caldwell E., Rea TD., Maier RV., et al. Development and validation of a prehospital prediction model for acute traumatic coagulopathy. Crit Care 2016; 20(1):371. Medline

Tranexamic Acid
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Mortality Patient PH-Paramedic Ker K. Antifibrinolytic drugs for acute traumatic injury. Cochrane Database of Systematic Reviews 2015:5. Medline
I Supportive (Green) Need for blood transfusion Patient OR Montroy J, Hutton B, Moodley P, Fergusson NA, Cheng W, Tinmouth A, Lavallée LT, Fergusson DA, Breau RH.The efficacy and safety of topical tranexamic acid: A systematic review and meta-analysis. Transfus Med Rev. 2018 [Epub ahead of print] Medline
I Supportive (Green) Death Patient ED-MD Roberts I., Shakur H., Coats T., et al. The CRASH-2 trial: A randomised controlled trial and economic evaluation of the effects of tranexamic acid on death, vascular occlusive events and transfusion requirement in bleeding trauma patients. Health Technol Assess 2013; 17(10):1-79. Medline
I Neutral (Yellow) 30-day mortality from trauma Patient PH-Paramedic & CCT Guyette FX, Brown JB, Zenati MS, Early-Young B, Adams PW, Eastridge BJ, et al. Tranexamic Acid during Prehospital Transport in Patients at Risk for Hemorrhage after Injury: A Double-blind, Placebo-Controlled, Randomized Clinical Trial. JAMA Surgery 2020. Medline
II Supportive (Green) Mortality Patient ED-MD Cole E., Davenport R., Willett K., Brohi K. Tranexamic acid use in severely injured civilian patients and the effects on outcomes: A prospective cohort study. Ann Surg 2015; 261(2):390-4. Medline
II Supportive (Green) Mortality Patient ED-MD Eckert MJ., Wertin TM., Tyner SD., Nelson DW., Izenberg S., Martin MJ. Tranexamic acid administration to pediatric trauma patients in a combat setting: The pediatric trauma and tranexamic acid study (PED-TRAX). J Trauma Acute Care Surg 2014; 77(6):852-8, discussion 858. Medline
II Supportive (Green) 24-hour mortality Patient PH-Paramedic El-Menyar A., Sathian B., Asim M., Latifi R., Al-Thani H. Efficacy of prehospital administration of tranexamic acid in trauma patients A meta-analysis of the randomized controlled trials. Am J Emerg Med 2018; 36(6) 1079-87. Medline
II Supportive (Green) In Hospital mortality at 24 and 48 hours Patient PH-Paramedic Morrison JJ., Dubose JJ., Rasmussen TE., Midwinter MJ.. Military application of tranexamic acid in trauma emergency resuscitation (MATTERs) study. Arch Surg 2012; 147(2):113-9. Medline
II Supportive (Green) In-hospital mortality Patient PH-Paramedic Morrison JJ., Ross JD., Dubose JJ., Jansen JO., Midwinter MJ., Rasmussen TE. Association of cryoprecipitate and tranexamic acid with improved survival following wartime injury: Findings from the MATTERs II study. JAMA Surg 2013; 148(3):218-25. Medline
II Supportive (Green) Mortality recorded at 24 hours Patient PH-Paramedic Neeki MM, Dong F, Toy J, Vaezazizi R, Powell J, Wong D, et al. Tranexamic Acid in Civilian Trauma Care in the California Prehospital Antifibrinolytic Therapy Study. The western journal of emergency medicine 2018; 19(6):977-86. Medline
II Supportive (Green) Blunting of measures of coagulopathy Patient PH-Paramedic & CCT Stein P., Studt JD., Albrecht R., Maller S., von Ow D, Fischer S., et al. The Impact of Prehospital Tranexamic Acid on Blood Coagulation in Trauma Patients. Anesth Analg 2018; 126(2) 522-9. Medline
II Neutral (Yellow) 30 day mortality Patient PH-MD & CCT Bossers SM, Loer SA, Bloemers FW, Den Hartog D, Van Lieshout EMM, Hoogerwerf N, et al. Association Between Prehospital Tranexamic Acid Administration and Outcomes of Severe Traumatic Brain Injury. JAMA Neurol 2021; 78(3):338-45. Medline
II Neutral (Yellow) In hospital mortality Patient ED-Paramedic & MD Boutonnet M., Abback P., Le Sachac F., Harrois A., Follin A., Imbert N., et al. Tranexamic acid in severe trauma patients managed in a mature trauma care system. The journal of trauma and acute care surgery 2018; 84(6) S54-62. Medline
II Neutral (Yellow) Hospital length of stay Patient Other Cornelius BG., McCarty K., Hylan K., Cornelius A., Carter K., Smith KWG., et al. Tranexamic Acid Promise or Panacea The Impact of Air Medical Administration of Tranexamic Acid on Morbidity, Mortality, and Length of Stay. Advanced emergency nursing journal; 40(1) 27-35. Medline
II Neutral (Yellow) Mortality Patient PH-Paramedic Neeki MM, Dong F, Toy J, Vaezazizi R, Powell J, Jabourian N, et al. Efficacy and Safety of Tranexamic Acid in Prehospital Traumatic Hemorrhagic Shock: Outcomes of the Cal-PAT Study. The western journal of emergency medicine 2017; 18(4):673-83. Medline
II Opposes (Red) Reliability Process PH-Paramedic Valle EJ., Allen CJ., Van Haren RM., et al. Do all trauma patients benefit from tranexamic acid? J Trauma Acute Care Surg 2014; 76(6):1373-1378. Medline
III Supportive (Green) management of hemorrhagic shick Patient PH-Paramedic Cathers AD, Forsythe J, Sippel N, Williamson C, Kohler JE, Brazelton TB, et al. Tranexamic Acid Use in Pediatric Hemorrhagic Shock From Farm-Related Trauma: A Case Report. Air Med J 2020; 39(5):414-6. Medline
III Supportive (Green) Efficacy Patient PH-Paramedic Vu EN, Wan WCY, Yeung TC, Callaway DW. Intramuscular Tranexamic Acid in Tactical and Combat Settings. Journal of special operations medicine: a peer reviewed journal for SOF medical professionals; 18(1):62-8. Medline
III Neutral (Yellow) Hyperfibrinolysis (ROTEM) Patient Kunze-Szikszay N., Krack LA., Wildenauer P., et al. The pre-hospital administration of tranexamic acid to patients with multiple injuries and its effects on rotational thrombelastometry: A prospective observational study in pre-hospital emergency medicine. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2016; 24(1):122. Medline
III Opposes (Red) Adverse event Patient ED-MD Carroll ND., Restrepo CS., Eastridge BJ., Stasik CN. Left atrial thrombi following tranexamic acid in a bleeding trauma patient-A word of caution. J Card Surg 2018; 33(2) 83-5. Medline
X Not Yet Graded (White) - Almuwallad A, Cole E, Ross J, Perkins Z, Davenport R. The Impact of Pre-Hospital TXA on Mortality among Bleeding Trauma Patients: A Systematic Review and Meta-Analysis. J Trauma Acute Care Surg 2021. Medline
X Not Yet Graded (White) - Kheirbek T, Jikaria N, Murray B, Martin TJ, Lueckel SN, Stephen AH, et al. Unjustified Administration in Liberal Use of Tranexamic Acid in Trauma Resuscitation. J Surg Res 2021; 258:125-31. Medline
X Not Yet Graded (White) - Patient Wafaisade A., Lefering R., Bouillon B., Bohmer AB., Gassler M., Ruppert M., et al. Prehospital administration of tranexamic acid in trauma patients. Crit Care 2016; 20(1):143-016-1322-5. Medline

Trendelenburg
Level Direction Primary Outcome Patient/Process Setting Reference
III Neutral (Yellow) MAP increase Patient ICU Sing RF., O'Hara D., Sawyer MAJ., Marino PL. Trendelenburg position and oxygen transport in hypovolemic adults. Ann Emer Med 1994; 23:564-7. Medline


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