COMBAT
Plasma-first resuscitation to treat haemorrhagic shock during emergency ground transportation in an urban area: a randomised trial
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Overview
During short urban ground transport, prehospital plasma did not improve 28-day survival compared with saline.
Clinical takeaway
COMBAT argues against routine prehospital plasma when ground transport to a mature urban trauma center is already measured in minutes.
Key result
In the as-treated analysis (125 of 144 randomized), 28-day mortality was 15% with prehospital plasma vs 10% with saline (not significant).
Practice impact
Do not assume prehospital plasma helps when transport times are already short.
Evidence
Study design
Pragmatic, randomized, single-centre trial.
Enrollment
144
Follow-up
Mortality within 28 days of injury.
Geography
United States
Clinical question
Does prehospital plasma during rapid urban ground transport reduce 28-day mortality in hemorrhagic shock compared with saline?
Population
- Consecutive trauma patients in hemorrhagic shock (SBP 70 mm Hg or lower, or SBP 71-90 mm Hg plus heart rate 108 or higher) assessed at the scene by paramedics.
Intervention
Two units of thawed plasma started during ground transport.
Comparator
Normal saline.
Primary outcome
Mortality within 28 days of injury.
In the as-treated analysis of 125 eligible patients, prehospital plasma during rapid urban ground transport did not reduce 28-day mortality compared with saline (15% vs 10%; P=0.37).
p=0.37
Key results
- 28-day mortality was 15% with plasma vs 10% with saline (P=0.37) in the as-treated analysis of 125 eligible patients.
- Median transport times were short in both groups (19 minutes with plasma vs 16 minutes with saline).
- The groups were similar at baseline; 56% required blood transfusion within 6 hours of injury.
- The trial was stopped for futility after 144 of 150 planned enrolments.
Harms
- In the intention-to-treat analysis, safety outcomes and adverse events did not differ significantly between groups.
Clinical Use
Practice impact
- Do not assume prehospital plasma helps when transport times are already short.
Applicability
- Most applicable to trauma patients in hemorrhagic shock during rapid ground rescue to an urban level 1 trauma center.
Limitations
- Single-center urban trial stopped early for futility.
- The as-treated analysis included 125 of 144 randomized patients.
- Median transport times were already short in both groups.
Common misinterpretations
- A negative urban ground trial does not refute prehospital plasma in longer-transport systems.
- The trial compared plasma with saline during transport, not with in-hospital balanced resuscitation.
Related evidence
Citation
Moore HB, Moore EE, Chapman MP, et al. Plasma-first resuscitation to treat haemorrhagic shock during emergency ground transportation in an urban area: a randomised trial. Lancet. 2018;392(10144):283-291. doi:10.1016/S0140-6736(18)31553-8
During rapid ground rescue to an urban level 1 trauma centre, use of prehospital plasma was not associated with survival benefit.
- PMID
- 30032977