Skip to main content

Timely completion of multiple life-saving interventions for traumatic haemorrhagic shock: a retrospective cohort study



Early control of haemorrhage and optimisation of physiology are guiding principles of resuscitation after injury. Improved outcomes have been previously associated with single, timely interventions. The aim of this study was to assess the association between multiple timely life-saving interventions (LSIs) and outcomes of traumatic haemorrhagic shock patients.


A retrospective cohort study was undertaken of injured patients with haemorrhagic shock who presented to Alfered Emergency & Trauma Centre between July 01, 2010 and July 31, 2014. LSIs studied included chest decompression, control of external haemorrhage, pelvic binder application, transfusion of red cells and coagulation products and surgical control of bleeding through angio-embolisation or operative intervention. The primary exposure variable was timely initiation of ≥ 50% of the indicated interventions. The association between the primary exposure variable and outcome of death at hospital discharge was adjusted for potential confounders using multivariable logistic regression analysis. The association between total pre-hospital times and pre-hospital care times (time from ambulance at scene to trauma centre), in-hospital mortality and timely initiation of ≥ 50% of the indicated interventions were assessed.


Of the 168 patients, 54 (32.1%) patients had ≥ 50% of indicated LSI completed within the specified time period. Timely delivery of LSI was independently associated with improved survival to hospital discharge (adjusted odds ratio (OR) for in-hospital death 0.17; 95% confidence interval (CI) 0.03–0.83; p = 0.028). This association was independent of patient age, pre-hospital care time, injury severity score, initial serum lactate levels and coagulopathy. Among patients with pre-hospital time of ≥ 2 h, 2 (3.6%) received timely LSIs. Pre-hospital care times of ≥ 2 h were associated with delayed LSIs and with in-hospital death (unadjusted OR 4.3; 95% CI 1.4–13.0).


Timely completion of LSI when indicated was completed in a small proportion of patients and reflects previous research demonstrating delayed processes and errors even in advanced trauma systems. Timely delivery of a high proportion of LSIs was associated with improved outcomes among patients presenting with haemorrhagic shock after injury. Provision of LSIs in the pre-hospital phase of trauma care has the potential to improve outcomes.


Haemorrhage is responsible for up to 50% of deaths after injury, and of these deaths, about half occur during the early stages of resuscitation [1]. Among those who reach the hospital, early mortality has been associated with continued haemorrhage, coagulopathy and incomplete resuscitation [2]. Once the injured patient develops the ‘triad of death’, outcomes are significantly worse and reversal of coagulopathy and control of haemorrhage becomes exceedingly difficult and, in some cases, efforts may be futile [3, 4].

Early control of haemorrhage and optimisation of physiology are therefore guiding principles of trauma resuscitation. Following airway maintenance and cervical spine control, chest decompression is critical when indicated [5]. The early maintenance of circulation and haemorrhage control involves control of external haemorrhage and anatomical approximation of fractures associated with bleeding, including splinting of the pelvis. These initial steps are able to be performed pre-hospital by most advanced emergency medical services.

In addition, the replacement of circulatory volume to maintain physiologically appropriate perfusion is recommended. Current evidence discourages the infusion of large volumes of crystalloid solutions with emphasis on early transfusion of red cells and pre-emptive transfusion of coagulation products to prevent and treat coagulopathy [6]. Red cell concentrates are available in some pre-hospital services, while availability of coagulation factors is uncommon. The ultimate aim of such interventions is to optimise physiology until definitive control of bleeding, with angiography or damage control surgery required in a small proportion of patients.

In contrast to single interventions, bundles of care for resuscitation after haemorrhagic shock and severe brain injury have been previously proposed [7]. Such bundles outline treatment recommendations when a single pathological process such as haemorrhagic shock or traumatic brain injury has been identified. Improved outcomes have been associated with compliance with such bundles [8]. At the same time, shorter times to isolated life-saving interventions (LSIs) have been associated with improved outcomes [9,10,11,12,13]. However, during the initial period of trauma resuscitation, either in the pre-hospital phase or during reception in the emergency department (ED), multiple LSIs are required for treatment of patients with injuries to multiple body regions [14]. Delays to completion of multiple critical interventions for such complex patients may be substantial and associated with poor outcomes [15,16,17]. In the absence of large trauma teams in well-resourced trauma centres, such interventions may not be able to be performed simultaneously but prioritised to be performed as soon as possible.

Even in advanced trauma systems, preventable mortality has been associated with failure to successfully intubate, secure or protect an airway, delayed operative or angiographic control of acute abdominal/pelvic haemorrhage and delayed intervention for ongoing intrathoracic haemorrhage [18]. However, in contrast to single interventions, the effect on mortality of multiple LSIs in a specified time period has not been adequately assessed. This study aimed to analyse patients with traumatic haemorrhagic shock and the association between timely initiation of defined LSIs and mortality.



This was a retrospective cohort study conducted within the Victoria State Trauma System that delivers more than 80% of severely injured patients to two adult major trauma services. Ambulance Victoria triages and transports all suspected adult major trauma patients directly to an adult Major Trauma Service when the travel time is less than 45 min. The Alfred Emergency & Trauma Centre (E&TC) admits in excess of 7500 trauma patients per year with over 1300 patients having an injury severity score of > 12 (abbreviated injury scale (AIS) 2008) [19]. The Alfred Hospital Trauma Registry (AHTR) staff collect trauma data concurrent with the inpatient episode. Regularly audited data are prospectively collected according to a defined dataset by experienced registry staff. AHTR staff collect data on all patients admitted for more than 24 h to The Alfred Intensive Care Unit or trauma patients with an Injury Severity Score (ISS) of more than 12 (AIS 2008) or trauma patients who die during the admission or all trauma patients requiring life-saving operative intervention. All severely injured patients immediately undergo a pre-defined set of pathology tests upon arrival to the E&TC [20]. This study was reviewed and approved by the Alfred Hospital Research & Ethics Committee.

Inclusion and exclusion criteria

All patients presenting to the E&TC directly from the scene of injury between July 1, 2010 and July 31, 2014 and entered into the AHTR were included. The population was limited to adult patients with haemorrhagic shock by including only patients with an initial (pre-hospital) systolic blood pressure (SBP) of < 100 mmHg and a heart rate (HR) of ≥ 100 beats/min. This definition of haemorrhagic shock based on a combination of hypotension and shock index has been previously proposed and shown to correlate with transfusion requirement in this population [21,22,23,24]. Patients with a diagnosed severe head injury (AIS of 5 or 6) were excluded from analysis. Also excluded were patients satisfying the above criteria, but with ISS < 12 and not undergoing any of the specified LSIs in the first 24 h [25].

Exposure variable

The exposure variable was defined as timely initiation of ≥ 50% of indicated LSIs. An intervention was considered to be indicated if performed within the first 12 h post injury. Time point 0 was taken as the best estimated time of injury as documented in pre-hospital clinical records, and the timing of each intervention when first started, either pre-hospital or in-hospital, was recorded. The LSIs and time limits are listed in Table 1. The list was selected from the key management protocols for breathing, ventilation and circulation in the Advanced Trauma Life Support Student Course Manual (8th edition), American College of Surgeons 2008 [26]. Pre-hospital time was defined as estimated time of injury to arrival time at the trauma centre. Pre-hospital care time was defined as arrival of paramedics at the scene to arrival at the trauma centre.

Table 1 Critical interventions for haemorrhagic shock

Indications for each intervention were dictated by local guidelines. Chest decompression was performed using set indications by pre-hospital clinical staff using needle thoracostomy and in-hospital after blunt dissection and digital decompression [27, 28]. Ambulance Victoria guidelines recommend application of a pelvic binder if a pelvic fracture is suspected. Resuscitation with red cells, in conjunction with a high ratio of plasma, is recommended in all massive haemorrhage protocols, with indications being poor response to initial crystalloid resuscitation [29]. Red cells were available in pre-hospital aeromedical services during the study period, but not in pre-hospital ground transport vehicles. Following early control of bleeding, restrictive volume replacement and prevention or early management of coagulopathy operative control of bleeding with adjunct use of interventional radiology were considered optimal practice [30].

Given the absence of reliable evidence for appropriate time limits to perform these interventions, conservative limits were set a priori by the authors of this study. This group of LSIs focused on critical treatment only and not investigations. Chest decompression was recorded as being initiated for any needle, finger or tube thoracostomy. External haemorrhage control was recorded if any external pressure or tourniquet was applied, Pelvic binder placement was defined as specialised device or sheet application was documented. Coagulation products included fresh frozen plasma (FFP), platelets and cryoprecipitate. As this trauma centre is currently enrolling in the pre-hospital anti-fibrinolytics for traumatic coagulopathy & haemorrhage (PATCH)-Trauma trial, E&TC administration of tranexamic acid was not routine and never in the initial stages of resuscitation during the period of this study [31]. Patients in whom < 50% of indicated LSIs were initiated within the defined time frames formed the delayed or comparator group.

Outcome variables

The primary outcome variable was in-hospital death. Secondary outcome variables were time to death and length of hospital stay among survivors. Potential confounders are listed. This list was kept parsimonious to account for the expected small sample of patients with the outcome variable of interest. ISS were based on AIS 2005: update 2008 and categorised [32]. Initial serum lactate level was used as a measure of acidaemia. Coagulopathy was recorded if the first measured international normalised ratio (INR) was > 1.5. This definition was based on previous studies that had concluded that an elevation of INR > 1.5 (and not mild elevations of > 1.2) was associated with mortality and morbidity after severe trauma [33].

Statistical analysis

Normally distributed continuous variables were summarised using mean (standard deviation (SD)) and differences between means assessed using Student’s t test. Skewed or ordinal variables were summarised using median (interquartile range) and statistical significance assessed using Wilcoxon rank-sum test. Differences in proportions were assessed using the chi-squared test. If potential confounders exhibited a statistical association with the outcome variable (p < 0.10) and were not plausibly in the causal pathway between the exposure and outcome variables, they were entered into a multivariable logistic regression model to determine independent associations with the primary outcome variable. Variables potentially in the causative pathway, i.e. pre-hospital times and time to LSIs, were not entered into the regression model but assessed with univariate associations. All analyses were performed using Stata v 11.3 (Statacorp, College Station, TX, USA). A p value of < 0.05 was considered to be statistically significant.


Patients eligible for inclusion and exclusion are outlined in Fig. 1. There were 168 patients included in this study. All patients underwent at least one of the pre-defined LSIs as outlined in Table 1. The number of patients that underwent LSIs and the univariate association with in-hospital mortality, together with proportion of timely LSIs, are listed in Table 2. There were 66 patients transported from the scene by helicopter, with no difference in proportion among the exposure and comparator groups. Focussed assessments with sonography for trauma (FAST) scans were performed on all patients on arrival to the E&TC.

Fig. 1
figure 1

Inclusion of patients for analysis of the association between multiple life-saving interventions and mortality at hospital discharge between July 1, 2010 to July 31, 2014. AHTR Alfred Hosptital Trauma Registry, ED emergency department, ISS injury severity score

Table 2 Patients undergoing timely individual interventions and the univariate association with in-hospital mortality

There were 54 (32.1%; 95% confidence interval (CI) 25.5–39.5) patients who received timely LSIs (at least 50% of indicated components performed within the pre-specified time limits). A comparison of patients who had timely interventions compared to those that had delayed interventions is listed in Table 3. Longer total pre-hospital times were associated with delayed LSI (Table 3; p < 0.01) and also in-hospital death (unadjusted odds ratio (OR) 1.37; 95% CI 1.02–1.83). Univariable associations between potential covariates to determine the independent association between timely LSI and in-hospital mortality are listed in Table 4. There was no univariate association between timely LSIs and in-hospital mortality (p = 0.86).

Table 3 Demographic, vital signs and management of patients that underwent life-saving interventions
Table 4 Association of demographic, vital signs and management variables with in-hospital mortality (univariable analysis)

There were 36 (21.4%) in-hospital deaths. After adjusting for confounders (age, pre-hospital care time, pre-hospital glasgow coma scale (GCS), initial lactate, ISS and coagulopathy), timely LSIs were associated with reduced odds of death at hospital discharge (OR 0.17; 95% CI 0.03–0.83; p = 0.028; Table 5). The Hosmer-Lemeshow test showed a Pearson chi-square of 3.23 and a p value of 0.92, indicating good calibration of the model. The association between pre-hospital times, completion of LSIs and in-hospital mortality is illustrated in Fig. 2. Among survivors, hospital length of stay for receiving a high proportion of timely LSIs was 22 (12–33) days and 15 (10–24) days among patients with delayed bundle (p = 0.17).

Table 5 Adjusted odds ratios for association of variables with in-hospital mortality
Fig. 2
figure 2

Association between pre-hospital time, delayed life-saving intervention (LSI) and in-hospital death of patients with haemorrhagic shock


This study demonstrated a significant association between timely LSIs in severely injured patients with haemorrhagic shock and their subsequent survival. The fact that this is significant, even in a large volume trauma centre, indicates a need for reassessment of the approach to providing care for the most severely injured. This study highlights that major trauma patients may benefit from a heterogeneous set of LSIs, which are needed to be individualised to the patient. Rather than ‘bundles of care’ for all patients, each patient required their ‘own bundle’, with certain components administered, at different times, but a high proportion needing timely delivery to achieve improved outcomes.

In the setting of long pre-hospital times, this research suggests that patients may benefit from LSIs delivered in the pre-hospital phase of trauma care. The findings are consistent with research in the combat setting, where LSIs were deemed to be required by most urgent casualties, and a delay in their performance associated with increased mortality. In this study, delays were noted for airway control, thoracostomy, control of external haemorrhage (tourniquet) and delivery of colloids [34]. The challenges of managing critically ill trauma patients in austere environments were noted.

Civilian guidelines in advanced trauma services recommending that severely injured patients be transported directly to appropriate trauma facilities may therefore subject patients to longer times in resource-poor environments being the back of an ambulance [35]. This not only has been almost universally associated with improved outcomes, but has also resulted in longer pre-hospital times. The combination of time to scene, scene time and then transport time results in long periods of initial care in the pre-hospital phase [36].

While the overarching evidence for primary transport to trauma centres remains strong, in the setting of haemorrhagic shock, strategies need to be individualised depending on time from trauma centres. Injured patients requiring prolonged pre-hospital care are a discrete subset of the military and civilian trauma populations. This may be due to remote location of the patient or delayed discovery after trauma. The pre-hospital phase of resuscitation is critical in these patients. In the military setting, the Special Operations Command Prolonged Field Care Working Group, composed of medical-specialty subject matter experts, has been tasked to evaluate the current training and preparedness of Special Operations Forces (SOF) medics [37]. It is recognised that the capacity to effectively resuscitate injured patients in the setting of PFC requires overarching capabilities and life-saving procedures, including the capability to resuscitate with blood and blood products, ventilate and oxygenate the patient and perform advanced surgical interventions such as tube thoracostomy insertion, fasciotomy, wound debridement and amputations [38].

Critical interventions after major trauma may be delayed due to delayed recognition of the life-threatening pathology, often difficult to detect in the pre-hospital phase of trauma care. Even after arrival to a trauma centre in advanced trauma systems, definitive airway management may be delayed [39]. In some cases, this may be appropriate while the circulation is prioritised, provided the airway is patent [40]. As such, this manuscript focused on LSIs that would be considered mandatory, rather than debatable during resuscitation of patients with haemorrhagic shock. Appropriate administration of blood and blood products is often delayed and associated with poor outcomes [41]. Algorithm based decision support systems may provide a solution, having been proven to reduce errors and improve times to critical interventions and is indicated to be applied to all phases of trauma resuscitation [42]. Such systems have demonstrated improved protocol compliance and reduction of errors of omission. In high-volume trauma centres, continuous presence of specialised staff at all hours improves assessment and management of complex, critically ill patients [43] and, with emerging technology, can readily connect trauma physicians to pre-hospital clinicians for added support [43]. Simple head or chest mounted video could also provide scene support for complex field decision-making. Ongoing improvements in pre-hospital and in-hospital assessments could further improved recognition for the need for LSIs, including point of care tests (such as lactate and viscoelastic measures of coagulation), ultrasound, and perhaps continuous vital signs analysis.

Limitations of this study include its single-centre population and retrospective nature. However, it involves a large proportion of state-wide, severely injured patients. Patients who died at the scene of trauma or in transit were not included in this study. The sample size was limited to patients where haemorrhagic shock would have been obvious from vital signs alone. This was designed to limit bias from delayed recognition resulting in delayed interventions [24]. While we attempted to limit co-variates, the final model was underpowered for the 36 patients in this study with the outcome of interest. Trauma resuscitation involves a complex set of tasks and it is possible that many other LSIs should be considered in some patients, and in its retrospective methodology, this study does not account for unknown confounders.

A distinct population of patients would have required LSIs without meeting our definition of obvious haemorrhagic shock and should form the population for future research. The small number of cases with outcome of interest limited the number of co-variates that could be included into the multivariable logistic regression analysis. The possibilities of significant unknown confounders are therefore high. Additionally, we evaluated timely initiation of care and not the quality of care. While we excluded patients with severe traumatic brain injury defined by AIS (head) 5 and 6, it is possible that head injury of AIS < 5 may have impacted on LSIs. For further assessment of quality, indications of the LSIs, effectiveness of chest decompression, accurate positioning of pelvic binders, blood and blood products in timely ratios and control of haemorrhage through surgery may be more appropriate exposure variables. Early assessments of coagulation disorders and goal-directed haemotherapy algorithms were not in place during the study period but have the potential to further improve patient outcomes [44].

Future research could focus on evidence-based time targets for assessment of and completion of LSIs for patients after traumatic haemorrhagic shock. Although a threshold of 50% was chosen for the proportion of indicated LSIs, in an ideal world, this proportion should be closer to 100%. In the pre-hospital phase, this should not delay scene or transport times, but rather be performed, where possible, en route to hospital. Improvements to current care processes were not specifically assessed in this study including early trauma resuscitation techniques such as open thoracostomies instead of needle decompression, in conjunction with training and audit [45], routine pelvic splints and tourniquets in the presence of shock and the use of haemostatic gauze [46,47,48]. Consistent evidence highlighting harm from crystalloid resuscitation should translate into alternate fluid therapy in the setting of haemorrhagic shock. Timely management of haemorrhage is widely recommended [49, 50]. The availability of red cells has improved over the last few years with availability in some pre-hospital services but needs to be accompanied by coagulation products, such as freeze-dried plasma and fibrinogen [51,52,53].


In a mature trauma system, a small proportion of severely injured patients had LSIs completed within ideal, specified time targets. Timely completion of multiple, rather than single, interventions were associated with improved outcomes. Timely LSIs by pre-hospital staff, in conjunction with primary transport to trauma centres, requires further evaluation in efforts to improve outcomes of severely injured patients in haemorrhagic shock.



Alfred Hospital Trauma Registry


Abbreviated Injury Scale


Confidence interval


Emergency & Trauma Centre


Focussed assessments with sonography for trauma


Heart rate


International normalised ratio


Injury Severity Score


Life-saving intervention


Odds ratio


Systolic blood pressure


Special operations forces


  1. Kauvar DS, Lefering R, Wade CE. Impact of hemorrhage on trauma outcome: an overview of epidemiology, clinical presentations, and therapeutic considerations. J Trauma. 2006;60(6 Suppl):S3–11.

    Article  Google Scholar 

  2. Koller M, Ernstberger A, Zeman F, Loss J, Nerlich M. Outcome after polytrauma in a certified trauma network: comparing standard vs. maximum care facilities concept of the study and study protocol (POLYQUALY). BMC Health Serv Res. 2016;16:242.

    Article  Google Scholar 

  3. Endo A, Shiraishi A, Otomo Y, Kushimoto S, Saitoh D, Hayakawa M, et al. Development of novel criteria of the “lethal triad” as an indicator of decision making in current trauma care: a retrospective multicenter observational study in Japan. Crit Care Med. 2016;44(9):e797–803.

    Article  Google Scholar 

  4. Mitra B, Cameron PA, Parr MJ, Phillips L. Recombinant factor VIIa in trauma patients with the ‘triad of death’. Injury. 2012;43(9):1409–14.

    Article  Google Scholar 

  5. de Lesquen H, Avaro JP, Gust L, Ford RM, Beranger F, Natale C, et al. Surgical management for the first 48 h following blunt chest trauma: state of the art (excluding vascular injuries). Interact Cardiovasc Thorac Surg. 2015;20(3):399–408.

    Article  Google Scholar 

  6. Feinman M, Cotton BA, Haut ER. Optimal fluid resuscitation in trauma: type, timing, and total. Curr Opin Crit Care. 2014;20(4):366–72.

    Article  Google Scholar 

  7. Shafi S, Collinsworth AW, Richter KM, Alam HB, Becker LB, Bullock MR, et al. Bundles of care for resuscitation from hemorrhagic shock and severe brain injury in trauma patients-translating knowledge into practice. J Trauma Acute Care Surg. 2016;81(4):780–94.

    Article  Google Scholar 

  8. Shafi S, Barnes SA, Rayan N, Kudyakov R, Foreman M, Cryer HG, et al. Compliance with recommended care at trauma centers: association with patient outcomes. J Am Coll Surg. 2014;219(2):189–98.

    Article  Google Scholar 

  9. Escott ME, Gleisberg GR, Kimmel K, Karrer A, Cosper J, Monroe BJ. Simple thoracostomy. Moving beyong needle decompression in traumatic cardiac arrest. JEMS. 2014;39(4):26–32.

    PubMed  Google Scholar 

  10. Powell EK, Hinckley WR, Gottula A, Hart KW, Lindsell CJ, McMullan JT. Shorter times to packed red blood cell transfusion are associated with decreased risk of death in traumatically injured patients. J Trauma Acute Care Surg. 2016;81(3):458–62.

    Article  Google Scholar 

  11. Krieg JC, Mohr M, Ellis TJ, Simpson TS, Madey SM, Bottlang M. Emergent stabilization of pelvic ring injuries by controlled circumferential compression: a clinical trial. J Trauma. 2005;59(3):659–64.

    PubMed  Google Scholar 

  12. Holcomb JB, del Junco DJ, Fox EE, Wade CE, Cohen MJ, Schreiber MA, et al. The prospective, observational, multicenter, major trauma transfusion (PROMMTT) study: comparative effectiveness of a time-varying treatment with competing risks. JAMA Surg. 2013;148(2):127–36.

    Article  Google Scholar 

  13. Lamb CM, MacGoey P, Navarro AP, Brooks AJ. Damage control surgery in the era of damage control resuscitation. Br J Anaesth. 2014;113(2):242–9.

    Article  CAS  Google Scholar 

  14. Brohi K, Cole E, Hoffman K. Improving outcomes in the early phases after major trauma. Curr Opin Crit Care. 2011;17(5):515–9.

    Article  Google Scholar 

  15. Mina MJ, Jhunjhunwala R, Gelbard RB, Dougherty SD, Carr JS, Dente CJ, et al. Factors affecting mortality after penetrating cardiac injuries: 10-year experience at urban level I trauma center. Am J Surg. 2017;213(6):1109–15.

    Article  Google Scholar 

  16. Gala PK, Osterhoudt K, Myers SR, Colella M, Donoghue A. Performance in trauma resuscitation at an urban tertiary level I pediatric trauma center. Pediatr Emerg Care. 2016;32(11):756–62.

    Article  Google Scholar 

  17. Reed MJ, Lone N, Walsh TS. Resuscitation of the trauma patient: tell me a trigger for early haemostatic resuscitation please! Crit Care. 2011;15(2):126.

    Article  Google Scholar 

  18. Gruen RL, Jurkovich GJ, McIntyre LK, Foy HM, Maier RV. Patterns of errors contributing to trauma mortality: lessons learned from 2,594 deaths. Ann Surg. 2006;244(3):371–80.

    PubMed  PubMed Central  Google Scholar 

  19. Palmer C. Major trauma and the injury severity score--where should we set the bar? Annu Proc Assoc Adv Automot Med. 2007;51:13–29.

    PubMed  PubMed Central  Google Scholar 

  20. Cameron PA, Gabbe BJ, Smith K, Mitra B. Triaging the right patient to the right place in the shortest time. Br J Anaesth. 2014;113(2):226–33.

    Article  CAS  Google Scholar 

  21. Vandromme MJ, Griffin RL, Kerby JD, McGwin G Jr, Rue LW 3rd, Weinberg JA. Identifying risk for massive transfusion in the relatively normotensive patient: utility of the prehospital shock index. J Trauma. 2011;70(2):384–8 discussion 8-90.

    Article  Google Scholar 

  22. Mutschler M, Nienaber U, Munzberg M, Wolfl C, Schoechl H, Paffrath T, et al. The Shock Index revisited - a fast guide to transfusion requirement? A retrospective analysis on 21,853 patients derived from the TraumaRegister DGU. Crit Care. 2013;17(4):R172.

    Article  Google Scholar 

  23. 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.

    Article  Google Scholar 

  24. Olaussen A, Peterson EL, Mitra B, O'Reilly G, Jennings PA, Fitzgerald M. Massive transfusion prediction with inclusion of the pre-hospital Shock Index. Injury. 2015;46(5):822–6.

    Article  Google Scholar 

  25. Newgard CD, Meier EN, McKnight B, Drennan IR, Richardson D, Brasel K, et al. Understanding traumatic shock: out-of-hospital hypotension with and without other physiologic compromise. J Trauma Acute Care Surg. 2015;78(2):342–51.

    Article  Google Scholar 

  26. Kortbeek JB, Al Turki SA, Ali J, Antoine JA, Bouillon B, Brasel K, et al. Advanced trauma life support, 8th edition, the evidence for change. J Trauma. 2008;64(6):1638–50.

    Article  Google Scholar 

  27. Bushby N, Fitzgerald M, Cameron P, Marasco S, Bystrzycki A, Rosenfeld JV, et al. Prehospital intubation and chest decompression is associated with unexpected survival in major thoracic blunt trauma. Emerg Med Australas. 2005;17(5–6):443–9.

    PubMed  Google Scholar 

  28. Fitzgerald M, Mackenzie CF, Marasco S, Hoyle R, Kossmann T. Pleural decompression and drainage during trauma reception and resuscitation. Injury. 2008;39(1):9–20.

    Article  CAS  Google Scholar 

  29. Mitra B, O'Reilly G, Cameron PA, Zatta A, Gruen RL. Effectiveness of massive transfusion protocols on mortality in trauma: a systematic review and meta-analysis. ANZ J Surg. 2013;83(12):918–23.

    Article  Google Scholar 

  30. Gruen RL, Brohi K, Schreiber M, Balogh ZJ, Pitt V, Narayan M, et al. Haemorrhage control in severely injured patients. Lancet. 2012;380(9847):1099–108.

    Article  Google Scholar 

  31. Mitra B, Mazur S, Cameron PA, Bernard S, Burns B, Smith A, et al. Tranexamic acid for trauma: filling the ‘GAP’ in evidence. Emerg Med Australas. 2014;26(2):194–7.

    Article  Google Scholar 

  32. Gennarelli TA, Wodzin E. Association for the Advancement of Automotive M. Abbreviated injury scale 2005 : Update 2008. Barrington, Ill: Association for the Advancement of Automative Medicine; 2008.

    Google Scholar 

  33. Peltan ID, Vande Vusse LK, Maier RV, Watkins TR. An international normalized ratio-based definition of acute traumatic coagulopathy is associated with mortality, venous thromboembolism, and multiple organ failure after injury. Crit Care Med. 2015;43(7):1429–38.

    Article  Google Scholar 

  34. Gerhardt RT, Berry JA, Blackbourne LH. Analysis of life-saving interventions performed by out-of-hospital combat medical personnel. J Trauma. 2011;71(1 Suppl):S109–13.

    Article  Google Scholar 

  35. Gabbe BJ, Lyons RA, Fitzgerald MC, Judson R, Richardson J, Cameron PA. Reduced population burden of road transport-related major trauma after introduction of an inclusive trauma system. Ann Surg. 2015;261(3):565–72.

    Article  Google Scholar 

  36. Harrington DT, Connolly M, Biffl WL, Majercik SD, Cioffi WG. Transfer times to definitive care facilities are too long: a consequence of an immature trauma system. Ann Surg. 2005;241(6):961–6 discussion 6-8.

    Article  Google Scholar 

  37. Ball JA, Keenan S. Prolonged field care working group position paper: prolonged field care capabilities. J Spec Oper Med. 2015;15(3):76–7.

    PubMed  Google Scholar 

  38. Butler FK, Smith DJ, Carmona RH. Implementing and preserving the advances in combat casualty care from Iraq and Afghanistan throughout the US military. J Trauma Acute Care Surg. 2015;79(2):321–6.

    Article  Google Scholar 

  39. Tan TXZ, Quek NXE, Koh ZX, Nadkarni N, Singaram K, Ho AFW, et al. The effect of availability of manpower on trauma resuscitation times in a tertiary academic hospital. PLoS One. 2016;11(5):e0154595.

    Article  Google Scholar 

  40. Fitzgerald MC, Lloyd-Donald P, Smit DV, Mathew J, Kim Y, Tee J, et al. Prehospital ground transport rapid sequence intubation for trauma and traumatic brain injury outcomes. Ann Surg. 2019;269(3):e29–30.

    Article  Google Scholar 

  41. Stanworth SJ, Davenport R, Curry N, Seeney F, Eaglestone S, Edwards A, et al. Mortality from trauma haemorrhage and opportunities for improvement in transfusion practice. Br J Surg. 2016;103(4):357–65.

    Article  CAS  Google Scholar 

  42. Fitzgerald M, Cameron P, Mackenzie C, Farrow N, Scicluna P, Gocentas R, et al. Trauma resuscitation errors and computer-assisted decision support. Arch Surg. 2011;146(2):218–25.

    Article  Google Scholar 

  43. Mitra B, Cameron PA, Fitzgerald MC, Bernard S, Moloney J, Varma D, et al. “After-hours” staffing of trauma centres and outcomes among patients presenting with acute traumatic coagulopathy. Med J Aust. 2014;201(10):588–91.

    Article  Google Scholar 

  44. Muensterer OJ, Lacher M, Zoeller C, Bronstein M, Kubler J. Google Glass in pediatric surgery: an exploratory study. Int J Surg. 2014;12(4):281–9.

    Article  Google Scholar 

  45. High K, Brywczynski J, Guillamondegui O. Safety and efficacy of thoracostomy in the air medical environment. Air Med J. 2016;35(4):227–30.

    Article  Google Scholar 

  46. Scott I, Porter K, Laird C, Greaves I, Bloch M. The prehospital management of pelvic fractures: initial consensus statement. Emerg Med J. 2013;30(12):1070–2.

    Article  CAS  Google Scholar 

  47. Lee C, Porter KM, Hodgetts TJ. Tourniquet use in the civilian prehospital setting. Emerg Med J. 2007;24(8):584–7.

    Article  CAS  Google Scholar 

  48. Zietlow JM, Zietlow SP, Morris DS, Berns KS, Jenkins DH. Prehospital use of hemostatic bandages and tourniquets: translation from military experience to implementation in civilian trauma care. J Spec Oper Med. 2015;15(2):48–53.

    PubMed  Google Scholar 

  49. Rossaint R, Bouillon B, Cerny V, Coats TJ, Duranteau J, Fernandez-Mondejar E, et al. The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Crit Care. 2016;20:100.

    Article  Google Scholar 

  50. Glen J, Constanti M, Brohi K. Assessment and initial management of major trauma: summary of NICE guidance. BMJ. 2016;353:i3051.

    Article  Google Scholar 

  51. Reynolds PS, Michael MJ, Cochran ED, Wegelin JA, Spiess BD. Prehospital use of plasma in traumatic hemorrhage (the PUPTH trial): study protocol for a randomised controlled trial. Trials. 2015;16:321.

    Article  Google Scholar 

  52. Sperry JL, Guyette FX, Brown JB, Yazer MH, Triulzi DJ, Early-Young BJ, et al. Prehospital plasma during air medical transport in trauma patients at risk for hemorrhagic shock. N Engl J Med. 2018;379(4):315–26.

    Article  Google Scholar 

  53. Yamamoto K, Yamaguchi A, Sawano M, Matsuda M, Anan M, Inokuchi K, et al. Pre-emptive administration of fibrinogen concentrate contributes to improved prognosis in patients with severe trauma. Trauma Surg Acute Care Open. 2016;1(1):e000037.

    Article  Google Scholar 

Download references


We would like to thank Ms. Louise Niggemeyer, Trauma Program manager for helping with the extraction of the data.


No funding was available or used for this study.

Availability of data and materials

The datasets generated during and/or analysed during the current study are not publicly available due conditions of the ethics committee approval but are available from the corresponding author on reasonable request and subject to ethics committee approval.

Author information

Authors and Affiliations



BM and PC designed the study. BM and JB extracted the data. The analyses were performed by BM and BB. MF and PC provided expert critical review. All authors were involved in the drafting of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Biswadev Mitra.

Ethics declarations

Ethics approval and consent to participate

This study was reviewed and approved by The Alfred Hospital Research & Ethics Committee. The requirement to obtain informed consent from patients was waived by the ethics committee.

Consent for publication

Not applicable. No identifiable information is presented.

Competing interests

The authors declare that they have no competing interests.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Mitra, B., Bade-Boon, J., Fitzgerald, M.C. et al. Timely completion of multiple life-saving interventions for traumatic haemorrhagic shock: a retrospective cohort study. Burn Trauma 7, 22 (2019).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: