Comparative efficacy of prehospital resuscitation strategies on mortality for patients with major trauma: a network meta-analysis

Background and importance Patients with major trauma face high rates of coagulopathy, hemorrhage, and organ failure, with prehospital resuscitation strategies critical for stabilization. Comparative evidence on prehospital blood [red blood cells (RBCs) and plasma] and non-blood [intravenous crystalloids and dextran, intravenous crystalloids only, and tranexamic acid (TXA)] resuscitation strategies remains limited and inconclusive. Objective(s) To evaluate and compare the efficacy of prehospital blood and non-blood resuscitation strategies in patients with major trauma using network meta-analysis. Design, settings, and participants Network meta-analysis of randomized controlled trials (RCTs). Databases: PubMed, CINAHL, Cochrane Library, and Web of Science and reference lists of relevant previous studies. Participants: patients with major trauma. Intervention or exposure Prehospital blood (RBC + plasma, RBC, and plasma) and non-blood (intravenous crystalloids + dextran, intravenous crystalloids only, and TXA) resuscitation strategies. Outcome measure and analysis Study outcomes were 24-h and 28-day mortality. Data analysis was performed using Frequentist and Bayesian frameworks on MetaInsight, an R-Language web-based analytical platform, presenting odds ratio (OR) and corresponding 95% confidence interval (95% CI). Ranking of prehospital resuscitation strategies was confirmed by the surface under cumulative ranking. Main results A total of 15 RCTs involving 7504 participants were included. Compared with intravenous crystalloids only, RBC + plasma (OR: 0.68, 95% CI: 0.38–1.22), plasma (OR: 0.72, 95% CI: 0.46–1.16), TXA (OR: 0.73, 95% CI: 0.52–1.04), RBC (OR: 0.81, 95% CI: 0.22–3.08), and intravenous crystalloids + dextran (OR: 0.91, 95% CI: 0.65–1.28) demonstrated no significant difference in reducing 24-h mortality. Similarly, TXA (OR: 0.83, 95% CI: 0.35–1.92), intravenous crystalloids + dextran (OR: 0.84, 95% CI: 0.46–1.52), RBC + plasma (OR: 0.88, 95% CI: 0.21–3.73), RBC (OR: 0.94, 95% CI: 0.10–8.64), and plasma (OR: 0.97, 95% CI: 0.38–2.46) revealed no significant difference in reducing 28-day mortality compared with intravenous crystalloids only. Based on ranking probabilities, RBC + plasma (65.8%) for 24-h mortality and TXA (74.6%) for 28-day mortality were ranked highest. Conclusion Prehospital blood (RBC + plasma, RBC, and plasma) and non-blood (intravenous crystalloids + dextran and TXA) resuscitation strategies were associated with comparable nonsignificant effects on early and late mortality. Current evidence is insufficient to support the superiority of a single prehospital intervention with future large-scale RCTs needed to clarify role of prehospital blood and non-blood resuscitation strategies.