Why Whole Blood Is Gaining Ground in Trauma Care 

Hemorrhage is the leading cause of death within the first hour of trauma care. According to the American College of Surgeons and Joint Trauma System, uncontrolled bleeding causes about 30% of trauma-related deaths in the U.S., making it the most common preventable cause of death in trauma.  

As trauma teams push to improve survival, one intervention is gaining renewed attention: whole blood.

The U.S. military started using whole blood in World War I, but it fell out of favor with blood component availability. Military air evacuations revived whole blood use in the early 2000s, and by 2016, most civilian air medical services carried it. Since then, whole blood use has steadily grown, especially in high-volume and Level I trauma centers.

The 2024 ESO Trauma Index offers a detailed analysis of current trends and benchmarks in trauma care, setting a new standard for improvement and allowing healthcare professionals to get a closer look at the data, understand its impact, and explore best practices for enhancing patient outcomes. Pulling data from the world’s largest de-identified trauma registry data program, the Index’s insights reflect over 975,433 trauma patient records that took place between January 1 and December 31, 2023. One of the key metrics covered in the Trauma Index is whole blood usage.

Key Findings

The 2024 ESO Trauma Index, for the first time, looked at all patients who received blood/blood products. Some of the key findings include:

• Among the almost 70,000 trauma patients who received a blood transfusion, 5% received whole blood only, 87% received packed red blood cells (PRBCs), and 8% received both whole blood and PRBCs. 
  
• The median time to whole blood delivery among all patients who received whole blood was 13 minutes. That’s good news.  
• For patients who met the Early Blood Transfusion Needs Score (EBTNS), a score of greater than five and received whole blood, 98% received whole blood within four hours, the goal. 
• The median time to transfusion for trauma patients who received PRBCs was 12 hours. Considering that 87% of transfusion recipients receive PRBCs, 12 hours is concerning.
  
  

Are PRBCs Enough? 

PRBCs remain a mainstay of trauma care. They help stabilize patients and support volume replacement during hemorrhage. But PRBCs alone can lead to over-resuscitation, clotting problems, or metabolic disturbances. The 2024 ESO Trauma Index shows that more than 50% of trauma patients arrive hypocalcemic. 

The increase in EMS agencies and trauma centers administering whole blood is driven by military and civilian research showing that early whole blood transfusion can significantly improve outcomes for patients in hemorrhagic shock.

Key Recommendations from the 2024 ESO Trauma Index 

Hospital trauma centers looking to strengthen transfusion practices should consider these best practices: 

• Track and review all transfusions administered within three hours of injury. 
• Monitor calcium levels during transfusion and provide supplementation. 
• Implement or refine massive transfusion protocols.  
• Administer TXA early, ideally within three hours of injury. 
• Use point-of-care coagulation testing (e.g., TEG, ROTEM) to guide treatment. 
• Develop rapid-access systems for blood products, even in non-critical scenarios. 

Yet, for all its good, whole blood remains expensive and challenging to manage. For trauma centers committed to incorporating whole blood, hospitals and EMS partners should: 

• Set clear protocols for blood handling, transfusion, and storage. 
• Coordinate closely with trauma centers and blood banks to manage supply. 
• Support community blood drives to maintain availability. 
• Provide ongoing training to EMS professionals administering blood products. 
  
  

Whole blood isn’t new, but its return is evidence-backed and outcome-driven. For trauma centers committed to faster intervention and better survival, it may be one of the most powerful tools available.

Want more whole blood benchmarks and guidance? Download the full 2024 ESO Trauma Index for the complete picture.