A Leg Up: Evaluating Ultramassive Transfusion after Extremity Vascular Injury

Extremity vascular injuries (EVI) are rare, life-threatening injuries that may require ultramassive transfusion (UMT), defined as transfusion of greater than or equal to 20 units of red cell products in 24 hours. This study aimed to evaluate outcomes of patients with EVI who required UMT and to determine which variables are associated with survival.

A retrospective, multicenter analysis was conducted of trauma patients who received UMT at 11 high-volume trauma centers from 2016 to 2024. Demographic, clinical, and outcome data were obtained and compared between patients with and without an EVI with subgroup analysis based on mortality.

A total of 1,155 patients received UMT and 194 (16.8%) had an EVI. The majority of these injuries (62.4%) were penetrating, and those with an EVI had a lower Injury Severity Score (30 vs 34, p < 0.01), underwent fewer resuscitative thoracotomies (19.1 vs 24.9%, p = 0.02), and fewer exploratory laparotomies (61.3 vs 82.7%, p < 0.01). Of all patients with EVI, 79 patients (40.7%) had an isolated EVI. More than half of patients with an EVI survived compared with only one-third without an EVI (50.5 vs 33.3%, p < 0.01). There was no difference in the transfusion of blood products. Among patients with EVI, survivors had a lower Injury Severity Score (27 vs 33, p < 0.01), higher initial heart rate (111 vs 87 beats per minute, p < 0.01), higher Glasgow Coma Scale score (10 vs 7, p < 0.01), higher initial platelet count (169 vs 140 × 10 3 /µL, p = 0.02), lower lactate (8.2 vs 12.5 mmol/L, p < 0.01), and smaller base deficit (11.5 vs 16.1 mmol/L, p < 0.01).

In patients who require UMT, EVI is associated with a higher rate of survival compared with those without EVI.