Prehospital whole blood for trauma: when two trials agree, the burden of proof shifts

Two pragmatic randomised trials, published back-to-back in the same issue, tested whether prehospital low-titre group O whole blood improves survival after traumatic haemorrhage. TOWAR cluster-randomised 44 North American air medical bases, and SWiFT randomised individual patients across 10 English air ambulance services. Both returned the same null. At a dose of 2 units, whole blood was not superior to conventional components, and neither trial signalled meaningful harm. TOWAR's cluster allocation, which left the whole blood arm sicker at baseline and tied the product a patient received to the month of injury, can bias its point estimate but cannot explain why an independent, cleanly randomised trial reached the same endpoint. The operational case for whole blood, less wastage and functional platelets, is less well supported than it appears. Neither trial compared whole blood with goal-directed factor concentrate resuscitation, which may be the stronger strategy.