Prehospital Transfusion Research Articles

More sophisticated than a drink cooler or an old sphygmomanometer but still not adequate for prehospital blood: A market review of commercially available equipment for prehospital blood transport and administration.

Hemorrhage is the leading cause of death in trauma patients with most fatalities occurring before reaching a higher level of care-this applies to both the civilian setting and the military combat setting. Hemostatic resuscitation with increased emphasis on blood transfusion while limiting use of crystalloids has become routine in trauma care. However, the prehospital setting-especially in combat-presents unique challenges with regard to storage, transport, and administration. We sought to evaluate available technology on the market for storage and administration technology that is relevant to the prehospital setting. We conducted a market review of available technology through subject-matter expert inquiry, reviews of published literature, reviews of Federal Drug Administration databases, internal military publications, and searches of Google. We reviewed and described a total of 103 blood transporters, 22 infusers, and 6 warmers. The risk of on-scene fatality in trauma patients and recent developments in trauma care demonstrate the need for prehospital transfusion. These transfusions have been logistically prohibited in many operations. We have reviewed the current commercially available equipment and recommended pursuit of equipment that improves accessibility to field transfusion. Current technology has limited applicability for the prehospital setting and is further limited for the military setting.

Coagulation function of never frozen liquid plasma stored for 40 days.

Never frozen liquid plasma (LP) has limited shelf life versus fresh frozen plasma (FFP) or plasma frozen within 24 h (PF24). Previous studies showed decreasing factor activities after Day (D)14 in thawed FFP but no differences between LP and FFP until D10. This study examined LP function through D40. FFP and PF24 were stored at -20°C until assaying. LP was assayed on D5 then stored (4°C) for testing through D40. A clinical coagulation analyzer measured Factor (F)V, FVIII, fibrinogen, prothrombin time (PT), and activated partial thromboplastin time (aPTT). Thromboelastography (TEG) and thrombogram measured functional coagulation. Ristocetin cofactor assay quantified von Willebrand factor (vWF) activity. Residual platelets were counted. FV/FVIII showed diminished activity over time in LP, while PT and aPTT both increased over time. LP vWF declined significantly by D7. Fibrinogen remained high through D40. Thrombin lagtime was delayed in LP but consistent to D40, while peak thrombin was significantly lower in LP but did not significantly decline over time. TEG R-time and angle remained constant. LP and PF24 (with residual platelets) had initially higher TEG maximum amplitudes (MA), but by D14 LP was similar to FFP. Despite significant declines in some factors in D40 LP, fibrinogen concentration and TEG MA were stable suggesting stored LP provides fibrinogen similarly to frozen plasmas even at D40. LP is easier to store and prepare for prehospital transfusion, important benefits when the alternative is crystalloid.

Making every drop count: reducing wastage of a novel blood component for transfusion of trauma patients

Recent research demonstrates that transfusing whole blood (WB=red blood cells (RBC)+plasma+platelets) rather than just RBC (which is current National Health Service (NHS) practice) may improve outcomes for major trauma patients....

Prehospital end-tidal carbon dioxide predicts hemorrhagic shock upon emergency department arrival.

In addition to reflecting gas exchange within the lungs, end-tidal carbon dioxide (ETCO2) also reflects cardiac output based on CO2 delivery to the pulmonary parenchyma. We hypothesized that low prehospital ETCO2 values would be predictive of hemorrhagic shock in intubated trauma patients. A retrospective observational study of adult trauma patients intubated in the prehospital setting and transported to a single Level I trauma center from 2016 to 2019. Continuous prehospital ETCO2 data were linked with patient care registries. We developed a novel analytic approach that allows for reflection of prehospital ETCO2 over the entire prehospital course of care. The primary outcome was hemorrhagic shock on emergency department (ED) presentation, defined as either initial ED systolic blood pressure of 90 mm Hg or less or initial Shock Index (SI) > 0.9, and transfusion of at least one unit of blood product during their ED stay. Prehospital ETCO2 less than 25 mm Hg was evaluated for predictive value of hemorrhagic shock. Three hundred and seven patients (82% men, 34% penetrating injury, 42% in hemorrhagic shock on ED arrival, 27% mortality) were included in the study. Patients in hemorrhagic shock had lower median ETCO2 values (26.5 mm Hg vs. 32.5 mm Hg; p < 0.001) than those not in hemorrhagic shock. Patients with prehospital ETCO2 less than 25 mm Hg were 3.0 times (adjusted odds ratio = 3.0; 95% confidence interval, 1.1-7.9) more likely to be in hemorrhagic shock upon ED arrival than patients with ETCO2 ≥ 25 mm Hg. Intubated patients with hemorrhagic shock upon ED arrival had significantly lower prehospital ETCO2 values. Incorporating ETCO2 assessment into prehospital care for trauma patients could support decisions regarding prehospital blood transfusion, and triage to higher-level trauma centers, and trauma team activation. Prognostic, level III.

Hypercoagulability in pregnant trauma patients

Circulating hormones affect coagulopathy in pregnancy and after trauma. The hemostatic profile of pregnant women after injury has not been characterized. We hypothesized that injured pregnant females would present with...

Hemostatic Resuscitation of Pediatric Trauma Patients During Air Medical Transport: A Retrospective Matched Cohort Study

ObjectiveThe objective of this study was to examine an academic air ambulance service's experience with prehospital transfusion of plasma and red blood cells in pediatric trauma for evidence of efficacy on the treatment of shock and coagulopathy. MethodsAll trauma patients < 18 years old transfused during transport by the University of Washington Airlift Northwest (Airlift) air medical transport service to Harborview Medical Center, Seattle, WA, were identified. Controls were matched 1:1 from pediatric trauma patients transported by Airlift before transfusion support became available. Demographics, injury scores, emergency department admission and interval laboratory values, blood product use, and hospital outcome measures were registered. ResultsSeventeen cases met the inclusion criteria and were matched by age and Injury Severity Score to 17 control patients (mean age = 10.5 vs. 10.9 years; New Injury Severity Score, 37 vs. 40.7). No significant differences in vital signs, shock index, or mortality were observed. Cases received less in-flight crystalloid (4.3 mL/kg vs. 16.9 mL/kg, P = .004), had higher admission fibrinogen levels (238 vs. 148mg/dL, P = .007), and shorter time to normalization of the international normalized ratio (6.4 vs. 19.1 hours, P = .04). ConclusionsIn this small series, hemostatic resuscitation during air medical transport was associated with less crystalloid administration and better support of coagulation indices.

Characteristics of Nontrauma Patients Receiving Prehospital Blood Transfusion with the Same Triggers as Trauma Patients: A Retrospective Observational Cohort Study

Objective: While prehospital blood transfusion (PHBT) for trauma patients has been established in many services, the literature on PHBT use for nontrauma patients is limited. We aimed to describe and compare nontrauma and trauma patients receiving PHBT who had similar hemodynamic triggers. Methods: We analyzed 3.5 years of registry data from a single prehospital critical care unit. The PHBT protocol included two packed red blood cell units and was later completed with two freeze-dried plasma units. The transfusion triggers were a strong clinical suspicion of massive hemorrhage and systolic blood pressure below 90 mmHg or absent radial pulse. Results: Thirty-six nontrauma patients and 96 trauma patients received PHBT. The nontrauma group had elderly patients (median 65 [interquartile range, IQR, 56–73] vs 37 [IQR 25–57] years, p < 0.0001) and included patients with gastrointestinal bleeding (n = 15; 42%), vascular catastrophes (n = 9; 25%), postoperative bleeding (n = 6; 17%), obstetrical bleeding (n = 4; 11%) and other (n = 2; 6%). Cardiac arrest occurred in nine (25%) nontrauma and in 15 (16%) trauma patients. Of these, 5 (56%) and 10 (67%) survived to hospital admission and 3 (33%) and 2 (13%) to hospital discharge. On admission, the nontrauma patients had lower hemoglobin (median 95 [84–119] vs 124 [108–133], p < 0.0001), higher pH (median 7.40 [7.27–7.44] vs 7.30 [7.19–7.36], p = 0.0015) and lower plasma thromboplastin time (median 55 [45–81] vs 72 [58–86], p = 0.0261) than the trauma patients. Conclusions: We identified four nontrauma patient groups in need of PHBT, and the patients appeared to be seriously ill. Efficacy of prehospital transfusion in nontrauma patients should be evaluated futher in becoming studies.

Acute traumatic coagulopathy and the relationship to prehospital care and on-scene red blood cell transfusion.

To identify the incidence of acute traumatic coagulopathy (ATC) in trauma patients presenting to the Royal Adelaide Hospital, analyse prehospital contributors, including red blood cell transfusion and assess the clinical significance of ATC. A retrospective database review was undertaken using conventional coagulation assays and viscoelastic testing (ROTEM) for diagnosis of ATC. Baseline ATC incidence is 10% in trauma patients, increasing to over 80% among those where the prehospital team has attended and given a transfusion of red cells. ATC was significantly associated with higher severity of trauma (odds ratio [OR] 1.11, P< 0.0001), prehospital (OR 11.8, P< 0.0001) and in-hospital blood transfusions (OR17.9, P< 0.0001), and massive transfusions (P< 0.001). Prehospital blood transfusions are given to the most severely injured trauma patients and the incidence of ATC in this group is more than 80%. There is an association with prehospital blood transfusion and increased ATC in part related to patient selection and severity of trauma, with the contribution of red cell transfusions to ATC unclear. This association should allow earlier identification of patients at increased risk of ATC to ensure rapid correction of coagulopathy to decrease the morbidity and mortality of trauma.

Operationalizing the Deployment of Low-Titer O-Positive Whole Blood Within a Regional Trauma System.

The implementation of a low-titer O+ whole blood (LTOWB) resuscitation algorithm, particularly in the prehospital environment, has several inherent challenges, including cost, limited and inconsistent supply, and the logistics of cold-chain management. The Southwest Texas Regional Advisory Council has implemented the nation's first multidisciplinary, multi-institutional regional LTOWB program. This research effort was to illustrate the successful deployment of LTOWB within a regional trauma system. A deliberate systems approach to the deployment of LTOWB was used. Tenets of this program included the active management of blood donor sources and blood supply levels to minimize wastage as a result of expiration, maximize product utilization, the use of prehospital transfusion triggers, and efforts to decrease program costs prehospital agencies. A novel LTOWB rotation system was established using the concept of a "rotation site" and "rotation center." Standardized transfusion criteria, a regional approved equipment list, a regional Prehospital Blood Product Transfusion Record, and a robust multilevel communication plan serves as the framework for the program. The San Antonio Whole Blood Consortium was developed to create a consensus driven forum to manage and guide the program. From January 2018 to October 2019, LTOWB has been placed at 18 helicopter emergency medical services (HEMS) bases, 12 ground emergency medical service (EMS) agencies, 1 level I trauma center, and 1 level IV trauma center. A total of 450 patients have received a prehospital LTOWB transfusion. Program wide, the wastage rate of LTOWB due to expiration is between 1% and 2%. No complications related to prehospital LTOWB administration have been identified. This work demonstrates a novel model for the development of a trauma system LTOWB program. The program's implementation augments remote damage control resuscitation strategies and requires the integration and collaboration of a multidisciplinary stakeholder team to optimize efficiency, performance, and safety of the program.

Blood Product Supply for a Helicopter Emergency Medical Service

Background: Long patient transport times to trauma centers are a well-known problem in sparsely populated regions with a low hospital density. Transfusion of red blood cell concentrates (RBC) and plasma improves outcome of trauma patients with severe bleeding. Helicopter emergency services (HEMS) are frequently employed to provide early advanced medical care and to reduce time to hospital admission. Supplying HEMS with blood products allows prehospital transfusion and may help to prevent exsanguination or prolonged hemorrhagic shock. We have investigated the maintenance of blood product quality under air transport conditions and the logistical steps to introduce a HEMS blood depot into routine practice. Methods: A risk analysis was performed and a validation plan developed. A special, commercially available transport container for blood products was identified. Maintenance of temperature conditions between 2 and 6°C in the box were monitored at ambient temperatures up to 35°C over 48 h. Quality of blood products before and after helicopter air transport were evaluated including (1) for RBCs: hemoglobin, hematocrit, hemolysis rate; (2) for thawed plasma: aPTT, INR, single clotting factor activities. The logistics for blood supply of the regional HEMS were developed by the transfusion service of the Greifswald University Hospital in collaboration with the in-hospital transport team, the HEMS team, and the HEMS operator. Results: The transport container maintained a temperature below 6°C up to 36 h at 35°C ambient temperature. Vibration during helicopter operation did not impair quality of RBC and thawed plasma. To provide blood products for HEMS at least two transport containers and an additional set of cooling tiles is needed as the cooling tiles need a special temperature priming over 20 h. The two boxes were used at alternate days. To reduce wastage, RBCs and thawed plasmas were exchanged every fourth day and reintegrated into the blood bank inventory for further in-hospital use. Conclusions: Supplying HEMS with RBCs and plasma is feasible. Helicopter transport has no negative impact on blood product quality. The logistic challenges require close collaboration between the HEMS team and the blood transfusion service.

Joint Trauma System Clinical Practice Guideline (JTS CPG): Prehospital Blood Transfusion. 30 October 2020.

This Clinical Practice Guideline (CPG) provides a brief summary of the scientific literature for prehospital blood use, with an emphasis on the en route care environment. Updates include the importance of calcium administration to counteract the deleterious effects of hypocalcemia, minimal to no use of crystalloid, and stresses the importance of involved and educated en route care medical directors alongside at a competent prehospital and en route care providers (see Table 1). With the paradigm shift to use FDA-approved cold stored low titer group O whole blood (CS-LTOWB) along with the operational need for continued use of walking blood banks (WBB) and point of injury (POI) transfusion, there must be focused, deliberate training incorporating the different whole blood options. Appropriate supervision of autologous blood transfusion training is important for execution of this task in support of deployed combat operations as well as other operations in which traumatic injuries will occur. Command emphasis on the importance of this effort as well as appropriate logistical support are essential elements of a prehospital blood program as part of a prehospital/en route combat casualty care system.

Prehospital Whole Blood Transfusion Programs in Norway

Background: Prehospital management of severe hemorrhage has evolved significantly in Norwegian medical emergency services in the last 10 years. Treatment algorithms for severe bleeding were previously focused on restoration of the blood volume by administration of crystalloids and colloids, but now the national trauma system guidelines recommend early balanced transfusion therapy according to remote damage control resuscitation principles. Materials and Methods: This survey describes the implementation, utilization, and experience of the use of low titer group O whole blood (LTOWB) and blood components in air ambulance services in Norway. Medical directors from all air ambulance bases in Norway as well as the blood banks that support LTOWB were invited to participate. Results: Medical directors from all 13 helicopter emergency medical services (HEMS) bases, the 7 search and rescue (SAR) helicopter bases, and the 4 blood banks that support HEMS with LTOWB responded to the survey. All HEMS and SAR helicopter services carry LTOWB or blood components. Four of 20 (20%) HEMS bases have implemented LTOWB. A majority of services (18/20, 90%) have a preference for LTOWB, primarily because LTOWB enables early balanced transfusion and has logistical benefits in time-critical emergencies and during prolonged evacuations. Conclusion: HEMS services and blood banks report favorable experiences in the implementation and utilization of LTOWB. Prehospital balanced blood transfusion using whole blood is feasible in Norway.

Prehospital Transfusion of Red Blood Cells and Plasma by an Urban Ground-Based Critical Care Team

Prehospital blood component therapy poses a possible treatment option among patients with severe bleeding. The aim of this paper was to characterize patients receiving prehospital blood component therapy by a paramedic-doctor-staffed, ground-based prehospital critical care (PHCC) service. Bleeding patients with a clinical need for prehospital blood transfusion were included prospectively. The following data were collected: indication for transfusion, mechanism of injury, vital parameters, units of red blood cells (RBCs)/plasma transfused, degree of shock, demographics, and mortality. Twenty-one patients received blood products: 12 (57%) traumatic injuries and nine (43%) non-traumatic bleeds, with a median of 1.5 (range 1.0-2.0) units of RBCs and 1.0 (range 0.0-2.0) unit of plasma. The most frequent trigger to initiate transfusion was on-going excessive bleeding and hypotension. Improved systolic blood pressure (SBP) and milder degrees of shock were observed after transfusion. Mean time from initiation of transfusion to hospital arrival was 24 minutes. In-hospital, 11 patients (61%) received further transfusion and 13 (72%) had urgent surgery within 24 hours. Overall, 28-day mortality was 29% at 24-hours and 33% at 28-days. Prehospital blood component therapy is feasible in a ground-based prehospital service in a medium-sized Scandinavian city. Following transfusion, patient physiology and degree of shock were significantly improved.

Infusion therapy of traumatic shock

Background. Analysis of all deaths due to military trauma (MT) over the last decade revealed that 1/4 of them could have been prevented. Up to 90 % of these deaths are related to blood loss. Trauma induces acute endogenous coagulopathy within a few minutes in 25 % of patients, which quadruples mortality. The main feature of MT is its combined nature, because in explosive injuries the local action of the explosion is combined with shrapnel wounds and distant damage to organs, and the wound canal goes through several anatomical parts of the body. In case of concomitant injuries, there are several sources of pain impulses, there is a deep endotoxicosis and impaired function of damaged organs. Under MT conditions, it is difficult to determine the nature of the shock due to a combination of hemorrhagic and traumatic shock. Uncontrolled post-traumatic bleeding is the leading cause of preventable death.&#x0D; Objective. To describe infusion therapy (IT) of shock.&#x0D; Materials and methods. Analysis of literature data on this issue.&#x0D; Results and discussion. In approximately 1/3 of hospitalized patients with trauma, the bleeding is coagulopathic. The severity of coagulopathy is determined by the influence of environmental factors, metabolic disorders, therapeutic strategy, the presence of brain and liver injuries, individual characteristics of the patient, the trauma and shock, hemodilution coagulopathy. The primary task of managing a patient with trauma is to eliminate the so-called lethal triad (hypothermia, acidosis, coagulopathy) and ensure perfusion of vital organs. Damage Control Resuscitation (DRC) is a systemic approach to the treatment of severe injuries that combines a resuscitation strategy with a range of surgical techniques from the moment of injury till the end of the treatment. DRC is aimed at blood loss minimization, maximization of tissue oxygenation, and optimization of outcomes. Surgeries performed as part of the DRC approach include an incision from the xiphoid process to the pubis with evacuation of blood and clots from the abdominal cavity, thorough examination and termination of all bleedings. Damaged parenchymal organs are completely resected. Damaged intestine is resected and connected with clips without anastomosis formation. Damaged vessels are ligated. The abdominal cavity is closed with a sterile bandage, but not sutured. After 1-2 days, tampons are removed, anastomoses are formed, and all non-viable tissues are removed. As for examinations, magnetic resonance imaging is the gold standard for assessing the severity of the injury and detecting extraperitoneal bleeding. In patients with closed abdominal trauma, hypotension, or an unknown mechanism of trauma, a rapid ultrasound examination is indicated to look for blood at potential sites of its accumulation. In the treatment of injuries with bleeding and shock, IT is of great importance. Its principles include the restriction of crystalloids use, the use of blood products in the optimal ratio of blood and plasma, and hypotension until the final surgical hemostasis. Reosorbilact (“Yuria-Pharm”) has properties close to an ideal infusion solution. The efficacy of Reosorbilact in shock was demonstrated in a multicenter Rheo-STAT study. In traumatic shock, infusion of 800 ml of Reosorbilact does not affect the coagulation hemostasis system. Instead, administration of a similar volume of 0.9 % NaCl is accompanied by a tendency to hypercoagulation, and 500 ml of hydroxyethyl starch – by hypocoagulation. Reosorbilact has a pronounced rapid hemodynamic effect. The target hemoglobin level in patients with trauma and bleeding is 70-90 g/L. Intravenous iron preparations (Sufer, “Yuria-Pharm”) can be used for its correction. Prehospital plasma transfusion is recommended to normalize coagulogram parameters. Tranexamic acid (Sangera, “Yuria-Pharm”) should be administered to patients with bleeding within 3 hours of injury. The first dose should be given at the prehospital stage of care. The pleiotropic effects of Sangera include antifibrinolytic, anti-allergic and anti-inflammatory. In addition, Sangera 2-3 times lowers the threshold of pain sensitivity. Another recommended component of comprehensive treatment of bleeding is the introduction of calcium chloride. Recombinant activated coagulation factor VII is not recommended for routine administration and is prescribed only when other measures are ineffective. It is recommended to urgently discontinue vitamin K antagonists and use appropriate antidotes. Pulmonary embolism is the third most common cause of death among patients with polytrauma who survived the third day. It is recommended to initiate the pharmacological thromboprophylaxis within 24 hours of bleeding control being achieved.&#x0D; Conclusions. 1. A significant proportion of preventable deaths are related to blood loss. 2. The primary task of managing a patient with trauma is to eliminate the lethal triad (hypothermia, acidosis, coagulopathy) and ensure perfusion of vital organs. 3. In the treatment of injuries with bleeding and shock, IT is of great importance. 4. Tranexamic acid should be administered to bleeding patients within 3 hours of injury.

Analysis of Prehospital Administration of Blood Products to Pediatric Casualties in Iraq and Afghanistan

Background Hemorrhage is one of the leading causes of preventable death in both military and civilian trauma. Implementation of items such as tourniquets and hemostatic dressings are helpful in controlling hemorrhage and increasing the survival rate of casualties when such injuries occur. Prehospital blood transfusions are used to treat patients with severe injuries where the standard methods of hemorrhage control are not an effective form of treatment. There is limited research and no widely accepted protocol on pediatric prehospital blood transfusions. Methods We queried the Department of Defense Trauma Registry (DODTR) for all pediatric subjects admitted to U.S. and Coalition fixed-facility hospitals in Iraq and Afghanistan from January 2007 to January 2016. This is a secondary analysis of casualties that received blood products prehospital. Results From January 2007 through January 2016 there were 3439 pediatric casualties within the registry. Within this group, 22 casualties that received one or more blood product prehospital were identified. Children in the 10–14 years age (40%) group made up the largest proportion, 86% were male, almost all were injured by explosive (63%) or firearm (27%), and 77% survived to hospital discharge. The most frequently administered blood product was packed red cells (n = 17). Of the 22, 15 underwent massive transfusion within the first 24 hours of admission. Conclusions Prehospital administration of blood products occurred infrequently within this pediatric dataset, but those that received blood were critically injured with most receiving a massive transfusion. Given the frequency with which medical personnel are carrying blood products in the prehospital, combat setting, guidelines specific to pediatric administration would be beneficial.

Pre-hospital hypothermia is associated with transfusion risk after traumatic injury.

In traumatically injured patients, excessive blood loss necessitating the transfusion of red blood cell (RBC) units is common. Indicators of early RBC transfusion in the pre-hospital setting are needed. This study aims to evaluate the association between hypothermia (<36°C) and transfusion risk within the first 24 hours after arrival to hospital for a traumatic injury. We completed an audit of all traumatically injured patients who had emergent surgery at a single tertiary care center between 2010 and 2014. Using multivariable logistic regression analysis, we evaluated the association between pre-hospital hypothermia and transfusion of ≥1 unit of RBC within 24 hours of arrival to the trauma bay. Of the 703 patients included to evaluate the association between hypothermia and RBC transfusion, 203 patients (29%) required a transfusion within 24 hours. After controlling for important confounding variables, including age, sex, coagulopathy (platelets and INR), hemoglobin, and vital signs (blood pressure and heart rate), hypothermia was associated with a 68% increased odds of transfusion in multivariable analysis (OR: 1.68; 95% CI: 1.11-2.56). Hypothermia is strongly associated with RBC transfusion in a cohort of trauma patients requiring emergent surgery. This finding highlights the importance of early measures of temperature after traumatic injury and the need for intervention trials to determine if strategies to mitigate the risk of hypothermia will decrease the risk of transfusion and other morbidities.

Pre-hospital blood transfusion \u2013 an ESA survey of European practice

BackgroundBlood products are a lifesaving commodity in the treatment of major trauma.Although there is little evidence for use of pre-hospital blood products (PHBP) in seriously injured patients, an increasing number of emergency medical services have started using PHBP for treatment of major haemorrhage.The primary aim of this survey was to establish the degree of prehospital blood product use throughout Europe and discover main indications. The secondary aim was to evaluate opinions about PHBP and also the experience and the personal views of its users.MethodsThe subcommittee for Critical Emergency Medicine of the European Society of Anaesthesiology (ESA) held an online survey of European Helicopter Emergency Services (HEMS) and all French Services d’Aide Médicale Urgente (SAMU) regions. It contained 13 questions both open and multiple-choice about the frequency transfusions are carried out, the PHBP used and the perceived benefit. The survey was distributed to the corresponding HEMS leads in 14 European countries.ResultsIn total there were 172 valid responses; overall 48% of all respondents have prehospital access to packed red cells, 22% to fresh plasma and 14% use lyophilised plasma. Besides blood product administration, 94% of all services use tranexamic acid. Sixty five percent of all replies came from French and from German services (37 and 28% respectively). PHBP were mainly used for trauma related emergencies. France has the highest uptake of use of blood products at 89%, whereas the rate in Germany was far lower at 6%.Fifty five percent of the service leads felt that PHBP are beneficial, and even lifesaving in individual cases despite being needed infrequently.ConclusionsWe found remarkable dissimilarities in practice between the different European countries. Even if there is not an absolute consensus amongst providers on the benefit of PHBP, the majority feel they are beneficial. The difference in practice is possibly related to the perceived lack of evidence on prehospital blood transfusion. We suggest to include the use of PHBP in trauma registries in order to consolidate the existing evidence.

Association of Prehospital Plasma Transfusion With Survival in Trauma Patients With Hemorrhagic Shock When Transport Times Are Longer Than 20 Minutes: A Post Hoc Analysis of the PAMPer and COMBAT Clinical Trials

Current guidelines emphasize early plasma transfusion and balanced transfusion in trauma patients with hemorrhagic shock. There have been 2 recent randomized control trials, the Prehospital Air Medical Plasma (PAMPer) trial and the Control of Major Bleeding After Trauma (COMBAT) trial, that took a closer look at initiating plasma transfusion even earlier - in the prehospital setting. These trials had contradicting results as the PAMPer trial showed improved survival and the COMBAT trial showed no benefit.

The shock index, pediatric age-adjusted (SIPA) enhanced: Prehospital and emergency department SIPA values forecast transfusion needs for blunt solid organ injured children

BackgroundThe elevated shock index, pediatric age-adjusted (SIPA) has been found to accurately predict the need for blood transfusion in severely injured children. We sought to determine the utility of monitoring sequential SIPA values from the prehospital setting through the emergency department to identify children with a blunt liver or spleen injury who will require a blood transfusion. MethodsWe conducted a retrospective review of children 1 to 18 years old admitted to a level-1 pediatric trauma center with any grade blunt liver or spleen injury between 2009 and 2019. Cohorts were stratified into those who received a blood transfusion within the first 24 hours after injury and those who did not. ResultsA total of 477 children had a blunt liver or spleen injury during the study period, of which 20% (95 of 477) received a blood transfusion within 24 hours of trauma center arrival. Of those who received a blood transfusion, 75% (71 of 95) were transfused within 6 hours of arrival at our center. Nearly 90% (84 of 95) of patients who received blood had at least 1 elevated SIPA score in either setting (prehospital or emergency department). Based on multivariable regression, an elevated SIPA score in either setting was significantly associated with blood transfusion (odds ratio 7.8 (confidence interval 4.7–12.9, P = .002). ConclusionElevated SIPA values in the prehospital setting and on emergency department arrival are associated with early blood transfusion. The importance of this finding is that after serial SIPA values may assist in the early identification of children with blunt liver or spleen injury who will require a blood transfusion.

Prehospital administration of blood products: experiences from a Finnish physician-staffed helicopter emergency medical service

BackgroundMassive infusions of crystalloids into bleeding hypotensive patients can worsen the outcome. Military experience suggests avoiding crystalloids using early damage control resuscitation with blood components in out of hospital setting. Civilian emergency medical services have since followed this idea. We describe our red blood cell protocol in helicopter emergency medical services (HEMS) and initial experience with prehospital blood products from the first 3 years after implementation.MethodsWe performed an observational study of patients attended by the HEMS unit between 2015 and 2018 to whom packed red blood cells, freeze-dried plasma, or both were transfused. The Student’s two-sided T-test was used to compare vitals in prehospital phase with those at the hospital’s emergency department. A p-value < 0.05 was considered significant.ResultsAltogether, 62 patients received prehospital transfusions. Of those, 48 (77%) were trauma patients and most (n = 39, 81%) suffered blunt trauma. The transfusion began at a median of 33 (IQR 21–47) minutes before hospital arrival. Median systolic blood pressure showed an increase from 90 mmHg (IQR 75–111 mmHg) to 107 mmHg (IQR 80–124 mmHg; P < 0.026) during the prehospital phase. Four units of red blood cells were handled incorrectly when unused red blood cells were returned and required disposal during a three-year period. There were no reported adverse effects from prehospital transfusions.ConclusionWe treated two patients per month with prehospital blood products. A prehospital physician-staffed HEMS unit carrying blood products is a feasible and safe method to start transfusion roughly 30 min before arrival to the hospital.Trial registrationThe study was retrospectively registered by the Tampere University Hospital’s Medical Director (R19603) 5.11.2019.