Prehospital transfusion strategies in haemorrhagic shock

BACKGROUND: Massive transfusion protocols are established in-hospital practices for managing haemorrhagic shock, yet critical bleeding accounts for up to 40% of trauma deaths, with half occurring before hospital arrival. This has driven interest in prehospital transfusion, a concept originating in military settings where early blood product administration during prolonged evacuations demonstrated significant survival benefits. Despite compelling military evidence showing improved 24-h and 30-day survival with prehospital transfusion, civilian adoption faces substantial challenges. Global interest in this domain is increasing, particularly in regions with trauma populations remote from immediate access to major trauma centres. MAIN BODY: Current prehospital transfusion strategies have evolved toward low titre group O whole blood utilisation, which offers simplified logistics, reduced donor exposures, and physiologic component ratios. There is a gap in evidence in prehospital transfusion strategies with a paucity of RCTs comparing whole blood to component therapy. A recent Cochrane review included 18 RCTs and 5041 patients. For prehospital transfusion strategies 5 studies compared use of plasma (fresh frozen plasma (FFP) or lyophilised plasma) versus 'standard of care', with uncertain effect of plasma on all-cause mortality at 24 h. Observational studies demonstrate four-fold increased survival rates with whole blood compared to component therapy and high-quality randomised controlled trials are ongoing. Implementation models vary from direct stocking at EMS stations to intercept and hospital-based approaches. Future research priorities include developing prediction scores for massive transfusion requirements, validating optimal physiological thresholds for transfusion initiation, and refining patient selection criteria. Comparative effectiveness research comparing whole blood against component therapy and alternative products is essential, as is evaluating injury pattern-based protocols. Technological innovations promise to address current limitations through artificial intelligence applications for predictive algorithms, universal blood products eliminating compatibility concerns, advanced storage technologies extending shelf life, drone-based delivery systems for remote access, and blockchain technology for enhanced traceability and safety. CONCLUSION: Prehospital transfusion represents a transformative paradigm shift in trauma care with potential to significantly reduce mortality worldwide. Success requires coordinated multi-stakeholder collaboration among EMS agencies, hospitals, blood suppliers, regulatory bodies, and research institutions. Continued focus on evidence-based practice, patient safety, and technological innovation will be essential to ensure life-saving blood products reach critically injured patients at the earliest possible moment, regardless of location.