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those who did not meet this criterion. This criterion was also Research Implications
associated with a 14-day mortality from bleeding or multi- Future studies should include collaborations with HEMS ser-
organ failure/and all-cause mortality of 20.6%/38% compared vices across provinces to support data trends observed and
to rates of 3%/6% when the criterion was not met. A similar quality improvement studies, including processes to optimize
association was found between post-HEMS transfusion hypo- resuscitation. Optimization of trauma systems, including stan-
tension and elevated INR. dardized prehospital and ED resuscitation tools that flag high-
risk patients for timely replacement of procoagulants, should
Our findings support what multiple studies have identified: also be studied.
there appears to be a direct relationship between initial fibrin-
ogen levels in trauma patients and survival. In our study Conclusion
2,8
cohort, the location of injury occurred a significant distance
from tertiary trauma care. The average times from injury to In our health records review, trauma patients transported by
HEMS patient arrival, and from patient arrival to ED, were HEMS with persistent hypotension after transfusion of pRBC
over 2 and 3 hours, respectively. HEMS’ average care time was by HEMS was associated with low ED arrival fibrinogen, co-
also around an hour and a half. The epidemiology of rural agulopathy, and mortality from hemorrhage and other causes.
trauma care and transport requires a targeted approach to
support patients prior to trauma center arrival. Author Contributions
Authors have made substantial contributions to the following:
Crystalloid usage was significant in our patient group, even the conception and design of the study (EC, SP, DOD, EC),
given EMS and HEMS guidelines to limit its use in traumatic acquisition of data (DOD, SP, JZ, AG, XC, CP), analysis and
hemorrhage. Though significant prehospital time and vital interpretation of data (all); drafting the article and revising it
sign derangement might have contributed, this does raise the critically for important intellectual content (all); final approval
question of how to best support the logistics of remote dam- of the version to be submitted (all).
age-controlled resuscitation and the administration of fluid in Disclaimer
cases remote from surgical control. The views expressed in this document are solely those of the
authors and do not necessarily represent those of their respec-
Previous Studies tive employers.
Only a third of patients in the CRYOSTAT-2 study presented
to the ED with an SBP<90. No difference was found in inter- Disclosures
vention when analyzing this subgroup, though this might be The authors have nothing to disclose.
due to delayed fibrinogen replacement on average over 1 hour
from ED arrival. Fibrinogen consumption progresses quickly Funding
3
during the first hours of trauma, and the benefits of fibrinogen No funding was received for this work.
replacement may be inversely related to the time at which the
product is given, though (as the CRYOSTAT-2 authors point References
4,5
out) perhaps only to those who are bleeding quickly and are 1. Moore EE, Moore HB, Kornblith LZ, et al. Trauma-induced co-
most coagulopathic. 3 agulopathy. Nat Rev Dis Primers. 2021;7(1):30. doi:10.1038/
s41572-021-00264-3
2. Inaba K, Karamanos E, Lustenberger T, et al. Impact of fibrinogen
Strengths and Limitations levels on outcomes after acute injury in patients requiring a massive
Limitations include the retrospective nature, small cohort, and transfusion. J Am Coll Surg. 2013;216(2):290–297. doi:10.1016/j.
the heterogeneity in prehospital resuscitation, such as seasons jamcollsurg.2012.10.017
and distances traveled (which may affect trauma coagulo pathy). 3. Davenport R, Curry N, Fox EE, et al. Early and empirical high-dose
While this study demonstrates with wide CIs a difference in out- cryoprecipitate for hemorrhage after traumatic injury: the CRYO-
STAT-2 randomized clinical trial. JAMA. 2023;330(19):1882–
come in hypofibrinogenemic patients, it remains unclear if pre- 1891. doi:10.1001/jama.2023.21019
hospital replacement of fibrinogen changes this outcome. 4. Itagaki Y, Hayakawa M, Maekawa K, et al. Early administration
of fibrinogen concentrate is associated with improved survival
Clinical Implications among severe trauma patients: a single-centre propensity score-
Our study objective was to identify prehospital variables pre- matched analysis. World J Emerg Surg. 2020;15(7). doi:10.1186/
s13017-020-0291-9
dictive of hypofibrinogenemia so that trauma patients likely 5. Mrochuk M, Ódochartaigh D, Chang E. Rural trauma patients can-
to develop low fibrinogen could be identified early, leading to not wait: tranexamic acid administration by helicopter emergency
targeted and expedited replacement. medical services. Air Med J. 2015;34(1):37–39. doi:10.1016/j.
amj.2014.09.004
Our finding suggests that CRC (or suspected major trauma 6. Weaver AE, Hunter-Dunn C, Lyon RM, Lockey D, Krogh CL. The
hemorrhage and persistent hypotension after initiation of pre- effectiveness of a ‘Code Red’ transfusion request policy initiated
by pre-hospital physicians. Injury. 2016;47(1):3–6. doi:10.1016/j.
hospital blood transfusion) could be used to predict patients injury.2015.06.023
with low fibrinogen. These findings could guide early fibrin- 7. von Elm E, Altman DG, Egger M, et al. The Strengthening the
ogen replacement in prehospital or ED setting. Over the last Reporting of Observational Studies in Epidemiology (STROBE)
year, STARS has started carrying fibrinogen concentrated at all statement: guidelines for reporting observational studies. J Clin Ep-
idemiol. 2008;61(4):344–349. doi: 10.1016/j.jclinepi.2007.11.008
six bases across three Canadian provinces. Following success- 8. Raza I, Davenport R, Rourke C, et al. The incidence and magni-
ful implementation in Saskatchewan, STARS is also expanding tude of fibrinolytic activation in trauma patients. J Thromb Hae-
the number of pRBC units that are carried from two to four most. 2013;11(2):307–314. doi:10.1111/jth.12078
units to support ongoing patient pre-trauma center resuscita-
tion. These measures support targeted interventions during
this crucial time of bleeding trauma patient care.

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