Publications

BACKGROUND: Air medical transport (AMT) has demonstrated a survival benefit for select patients. The Air Medical Prehospital Triage (AMPT) score identifies patients with a survival benefit from AMT. Patients with positive AMPT score may be heterogenous with different levels of benefit. Our objective was to identify phenotypes of injured patients with a positive AMPT score with differential benefits of AMT compared with ground emergency medical services.

METHODS: Patients 16 years or above transported by AMT or ground emergency medical services from the scene (>3 and <40 miles) and met AMPT score criteria in the Pennsylvania Trauma Outcomes Study 2000-2017 were included. Patients were clustered using latent class analysis (LCA) and k-modes clustering. From the two class memberships, we then assessed the association between in-hospital survival and actual transport mode using multilevel generalized linear models, adjusting for demographics, injury characteristics, vital signs, and in-hospital variables. To validate our membership assignments, the same analysis was performed on separately on NTDB data.

RESULTS: In total, 22,569 patients were included from the Pennsylvania Trauma Outcomes Study, with 7,607 (35%) actually undergoing AMT. LCA resulted in five phenotype classes. Among these, Class 2, composed of patients with physiological plus anatomic triage criteria and Glasgow Coma Scale (GCS)≤13, and Class 5, composed of a GCS≤13 plus abnormal respiratory rate, demonstrated profound survival benefit [aOR, 1.83 (1.41, 2.36) and 2.23 (1.76, 2.81)]. K-modes also resulted in five classes. Among these, Classes 2, 4, and 5 also composed of patients with physiological plus anatomic criteria, GCS≤13 and/or abnormal respiratory rate. These groups also demonstrated profound survival benefit [aOR, 1.85 (1.33, 2.59), 2.02 (1.49, 2.73) and 2.5 (1.97, 3.17)]. Replication in NTDB illustrated similar results.

CONCLUSIONS: These findings suggest that patients with GCS≤13 and abnormal respiratory rate or physiological plus anatomic triage criteria should be prioritized in AMT use. (J Trauma Acute Care Surg. 2026;00: 00-00. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.).

LEVEL OF EVIDENCE: Prognostic; Level IV.

BACKGROUND: Thrombotic and thromboembolic events are a common and potentially preventable complication in multitrauma patients, and substantial quality improvement efforts are directed at prevention. The results of several randomized controlled trials (RCTs) related to the association between tranexamic acid (TXA) and thrombotic/thromboembolic events have demonstrated conflicting results. We aimed to address this by examining whether prehospital TXA was associated with higher rates of thrombotic/thromboembolic events in a harmonized data set from three large multicenter RCTs.

METHODS: We analyzed data using a harmonized data set from three RCTs examining the effects of prehospital TXA: The Pre-Hospital Anti-fibrinolytics for Traumatic Coagulopathy and Hemorrhage Study (PATCH trial), Study of Tranexamic Acid During Air and Ground Medical Prehospital Transport Trial (STAAMP trial) and the Prehospital TXA for TBI trial, part of the Resuscitation Outcomes Consortium (ROC trial). Outcomes included deep venous thrombosis (DVT), pulmonary embolism (PE), myocardial infarction, stroke, combined venous thrombotic/thromboembolic events (VTE), and combined arterial thrombotic/thromboembolic events. Multivariable regression was used to adjust for TXA administration, sex, age, injury severity score, Glasgow Coma Scale, shock index, and 24-hour red cell transfusion.

RESULTS: There were no differences in myocardial infarction, stroke, arterial thrombotic/thromboembolic events, DVT, PE, or VTE in patients who were randomized to TXA compared with those who were not. On univariate analysis, rates of PE, DVT and VTE were significantly higher in the PATCH cohort compared with STAAMP and ROC cohorts, but patients in PATCH had significantly higher injury severity scores and chest trauma when compared with those in ROC and STAAMP.

CONCLUSION: This multicenter database combining three large RCTs showed that randomization to TXA was not associated with higher rates of arterial and VTE. The higher rates of thrombotic/thromboembolic events observed in the PATCH trial may be explained by higher injury severity as well as protocolized screening. (J Trauma Acute Care Surg. 2026;00: 000-000. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.).

LEVEL OF EVIDENCE: Sub-analysis of randomized controlled trials; Level II.

Platelet transfusions to treat bleeding complications use donor-derived platelets stored at room-temperature, that have a shelf-life of only 5-7 days due to bacterial contamination risks. Cold-stored and freeze-dried platelets are being investigated for extending shelf-life, but these still have the inherent challenge of donor-dependency. To address this, we developed a liposome-based synthetic platelet (SP) nanoconstruct that mimics the primary hemostatic mechanisms of platelets, and have previously reported its efficacy. However, a logistical limitation of SP is its susceptibility to environment-induced physico-chemical instabilities that reduces shelf-life when stored as aqueous suspension, impacting its availability and bioactivity. Lyophilization of liposomal nanotherapeutics utilizing anhydrobiosis-inspired lyoprotectants can enhance shelf-life, but this has not been explored for synthetic platelets. With these considerations, we report advancing SP into a lyophilized product (Lyo-SP) that can be rapidly aqueous-reconstituted for on-demand use. Lyo-SP retained morphology, size, and charge in long-term storage at various temperatures, and conserved platelet-mimetic functions in multiparametric assays with human plasma and blood. Lyo-SP demonstrated biosafety in its effect analysis on endothelial cells, neutrophils, RBCs and complement C3. Lyo-SP significantly reduced bleeding in a tail-clip model in thrombocytopenic mice. These studies establish the potential of Lyo-SP as a shelf-stable platelet surrogate for treating bleeding complications.

BACKGROUND: Substituting group A whole blood (GAWB) might relieve some of the burden on the low titer group O whole blood (LTOWB) inventory. This simulation examined the effect of implementing GAWB at a large trauma hospital.

STUDY DESIGN AND METHODS: A civilian trauma center with LTOWB and GAWB par levels set to 22 and 10 units, respectively, was modeled as the baseline. The average daily number of WB recipients was 0.5 who received an average of four WB units per patient. LTOWB was issued in packages of five and all had to be consumed before a group A patient could be switched to GAWB. Several variations on the baseline simulation were also modeled.

RESULTS: In the baseline simulation, there was a median (interquartile range, IQR) of 1 (0-2) GAWB and 16 (13-19) LTOWB recipients per month. The median (IQR) GAWB and LTOWB units transfused per month was 2 (0-9) and 56 (42-72), respectively. Fourteen percent of group A patients received any quantity of GAWB. The variations that had the most impact on GAWB usage included increasing the number of WB recipients to 2.5 per day where the median (IQR) monthly number of GAWB recipients and units transfused increased to 4 (3-5) recipients and 21 (12-29) units, respectively, and when the average WB requirements increased to eight units per patient resulting in transfusing a median (IQR) of 10 (5-15) GAWB units per month to 3 (1-4) recipients.

DISCUSSION: Under routine civilian hospital circumstances, implementing GAWB will have a modest impact on LTOWB inventory.

BACKGROUND: Low Titer Group O Whole Blood (LTOWB) use has expanded to include patients with non-traumatic bleeding etiologies. While a large body of evidence supports a potential survival benefit of LTOWB in trauma patients, data demonstrating the safety and efficacy of LTOWB in non-trauma patients are lacking.

STUDY DESIGN AND METHODS: Non-trauma adult patients at two hospitals who received at least one unit of LTOWB were included in the study. Patient demographics, transfusion and laboratory data, diagnoses, mortality, and hospital length of stay were collected between January 1, 2018, and June 30, 2024. LTOWB recipients were further stratified by O versus non-group O blood group, and laboratory markers of renal failure and hemolysis were compared between these two groups.

RESULTS: A total of 319 unique patients with 320 LTOWB transfusion episodes were included. The most common indications for transfusion were gastrointestinal and cardiovascular bleeding (266/320, 83%). In-hospital survival at 24 h and 30 days posttransfusion was 75% and 53%, respectively. There was no statistically significant difference in markers of hemolysis between group O and non-group O LTOWB recipients. There were no reported transfusion reactions.

DISCUSSION: In non-trauma settings, LTOWB was most commonly utilized in patients with gastrointestinal and cardiovascular bleeding. LTOWB is a safe alternative to component therapy in non-trauma adult populations. However, additional studies are needed to focus on efficacy and clinical outcomes in non-trauma patients that receive LTOWB for severe hemorrhage.

BACKGROUND: Early transfusion improves survival of traumatic hemorrhage. We hypothesized that increased ratios of prehospital to total blood (red blood cell or whole blood) transfusion within 24 hours would be associated with improved outcomes.

METHODS: A retrospective cohort study using a harmonized database of six hemorrhagic shock trials was conducted. Decedents within 4 hours and those not transfused within 24 hours were excluded. The primary outcome was 24-hour mortality; secondary outcomes included 28-day mortality, intensive care unit (ICU)-free and ventilator-free days, and incidence of acute lung injury (ALI). Prehospital blood ratio was calculated as volume prehospital transfusion:volume 24-hour total transfusion (prehospital plus 24-h total at the admitting facility). Multivariable analyses adjusted for age, sex, mechanism, Injury Severity Score (ISS), inter-facility transfer, transport mode, arrival systolic blood pressure and Glasgow Coma Scale, treatment group, trial, and transfusion volume were conducted. Sensitivity analyses (prehospital-only recipients, excluding traumatic brain injury) were conducted.

RESULTS: Overall, 2,340 subjects were eligible, and 1,024 (43.8%) received prehospital blood. Prehospital recipients were older (median age 41 vs. 38 y, P=0.013), more likely blunt mechanism (81.6% vs. 66.0%; P<0.001), more likely transferred (13.3% vs. 4.3%; P<0.001), more likely transported by air (77.4% vs. 47.1%; P<0.001), and had higher ISS (median 29 vs. 25, P<0.001) compared with in-hospital only recipients. For every 10% increase in prehospital (PH):total blood ratio, there was an 8.8% decrease in odds of ALI (95% CI: 1.8-15.4%; P=0.015) and no significant association with mortality, ICU-free or ventilator-free days. Among prehospital recipients, for every 10% increase in PH:total blood ratio, there was a 16.7% decrease in odds of ALI (95% CI: 5.3-26.6%; P=0.005; n=375) and 0.21 (95% CI: 0.01-0.41; P=0.036; n=909) more ICU-free days.

CONCLUSIONS: An increased proportion of resuscitation in the prehospital phase of care was associated with improved secondary clinical outcomes for select subjects. These data support initiating transfusion for hemorrhage as early as feasible. (J Trauma Acute Care Surg. 2026;00: 000-000. Copyright© 2026 Wolters Kluwer Health, Inc. All rights reserved.).

LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

BACKGROUND: Hemorrhage is the leading cause of preventable death in severe trauma, with primary hemostasis relying on platelet-rich clot formation under high shear flow. This study quantifies the incidence, severity, and heterogeneity of platelet dysfunction in Level I trauma patients.

STUDY DESIGN AND METHODS: A whole blood assay mimicking arterial hemorrhage fluidic conditions was used to measure platelet-rich clot formation in Level I trauma patients. Blood samples from patients were collected at arrival and tested for defects in platelet clotting immediately and after 12, 24, and 48 h. Additional clinical parameters such as injury severity, complete blood counts, and blood product use were collected.

RESULTS: The high shear assays were completed in under 5 min using 3 mL of blood. All trauma patients exhibited severe defects in platelet clotting at various time points compared to control blood from healthy donors (p < .01). Platelet function varied over time, with some patients exhibiting initial hyper-clotting followed by dysfunction at 24 h, while others showed persistent impairment for the entire 48 h.

DISCUSSION: The rapid assay was able to distinguish heterogeneous platelet dysfunction in Level I trauma patients. The assay enabled real-time tracking of a patient's platelet clotting function and response to interventions. By identifying patients with impaired hemostatic function, this assay could potentially inform targeted resuscitation strategies to improve trauma care outcomes.

BACKGROUND: The optimal thromboprophylaxis among critically ill adults with COVID-19 is uncertain.

OBJECTIVES: To determine the effectiveness and safety of intermediate-dose heparin compared to standard low-dose thromboprophylaxis.

PATIENTS/METHODS: In an ongoing adaptive platform trial (REMAP-CAP), critically ill patients with COVID-19 were randomized to intermediate-dose heparin or standard low-dose thromboprophylaxis. Interventions were continued in hospital for up to 14 days. The primary endpoint was organ support-free days (OSFDs), an ordinal outcome combining in-hospital survival and the number of days free of ICU-based respiratory or cardiovascular organ support through 21 days. The primary analysis was an adjusted Bayesian hierarchical cumulative logistic model. An odds ratio (OR)> 1.0 represents an improved outcome with intermediate-dose heparin.

RESULTS: Between 27 April 2021 and 25 November 2023, 1255 critically ill adults with COVID-19 were enrolled from 78 sites in 15 countries, of whom 1254 completed follow-up (n=572 intermediate-dose, n=682 low-dose). Enrolment was terminated prior to reaching a pre-specified statistical trigger due to declining case numbers and slow recruitment. Median age was 59 years and 36.7% were female (n=461/1255). The probability that intermediate-dose heparin improved OSFDs was 73.5% (OR: 1.06, 95% credible interval (CrI): 0.87, 1.30) which did not meet the pre-specified superiority threshold of 99%. Hospital survival was 77.1% (441/572) and 76.7% (523/682) in the intermediate and low-dose heparin groups respectively (median adjusted OR:1.14 (95% CrI:0.86, 1.52). Major bleeding occurred in 10/572 (1.7%) and 14/682 (2.1%) of patients receiving intermediate and standard low-dose respectively.

CONCLUSION: Intermediate-dose heparin did not improve organ support-free days or survival compared with standard thromboprophylaxis in critically ill patients with COVID-19. (ClinicalTrials.gov number:CT02735707).