Written by Michael Stocker
Spoon Feed
In cases of severe traumatic hemorrhage, prehospital whole blood (WB) transfusion did not outperform component therapy in reducing mortality or need for massive transfusion within 24 hours.
The whole is not greater than the sum of its parts
In recent years, WB has taken center stage as the treatment of choice in traumatic hemorrhagic shock, but does it outperform component therapy in the critical care air transport (HEMS) setting? SWiFT was a pragmatic randomized superiority trial of WB versus 1:1 pRBC:plasma. While 942 patients were randomized, after exclusions (e.g. nontraumatic hemorrhage, traumatic arrest) 641 patients receiving up to 2 units of WB (n=327) or 2:2 units of pRBC:plasma (n=314) were included in the analysis. The trial did not prescribe initiation criteria, leaving transfusion triggers up to the clinical judgment of the 10 participating UK HEMS services. The primary outcome was a composite of all-cause mortality and need for massive transfusion within 24 hours, with several secondary outcomes including mortality from 6 hours to 90 days, total transfusion volume, and safety events. Both groups had similar demographics and clinical characteristics.
Neither the modified intention-to-treat (48.7% vs. 47.7%, RR 1.02, 95%CI 0.80–1.31, p=0.84) nor per-protocol analyses found WB to be superior in the composite primary outcome. Few differences were identified in the secondary outcomes, though a higher percentage of the WB group had prolonged prothrombin time (40.7% vs. 30.5%) and more adverse events occurred in the component group (37% vs. 31%). While composite outcomes limit interpretation, similar conclusions can be drawn from the secondary outcomes.
How will this change my practice?
Despite logistic simplicity, I remain a late adopter of prehospital whole blood. It is too scarce a resource to tolerate the potential waste and diversion away from resuscitation bays and ORs without clear benefit. That said, I eagerly await the results of TOWAR.
Source
Prehospital Whole Blood in Traumatic Hemorrhage – a Randomized Controlled Trial. N Engl J Med. 2026 Mar 17. doi: 10.1056/NEJMoa2516043. Epub ahead of print. PMID: 41841706.
