Stewardship of Prehospital Low Titer O-Positive Whole Blood in a Large Urban Fire-Based EMS System.

Introduction: Trauma is the leading cause of death for those aged 1 to 46 years with most fatalities resulting from hemorrhage prior to arrival to hospital. Hemorrhagic shock patients receiving transfusion with 15 minutes experience lower mortality. Prehospital blood transfusion has many legal, fiduciary, and logistical issues. The San Antonio Fire Department participates in a consortium designed to enhance the stewardship of prehospital whole blood. This study aimed to stratify blood usage amongst the field supervisors and special operations units that carry whole blood. Methods: This was a 12-month retrospective analysis of blood usage. Blood tracking forms (used for either blood exchange of transfusion) were cross referenced with city financial records to determine blood usage patterns in the 7th Largest City in the US. We used descriptive statistics, compared usage ratios, and chi-square to compare dichotomized data. Results: A total of 363 whole blood units were obtained and 248 (68.3%) units of whole blood were transfused. EMS field supervisors transfused 74% of whole blood vs. 44% for special operations ambulances (p= <0.001). Response vehicles located in densely populated areas had the highest usage rates. All blood units were either transfused or returned for a zero blood unit wastage for expiration. Conclusion: The information contained within this work can provide other EMS agencies with a basic framework for comparison. The data from the SAFD's whole blood transfusion rate coupled with the clinical transfusion guideline has provided some insight for prospective agencies considering adopting a whole blood program. EMS systems and municipalities with similar characteristics can project their own whole blood needs and make informed decisions regarding program feasibility and design.

Prehospital whole blood reduces early mortality in patients with hemorrhagic shock.

BACKGROUND: Low titer O+ whole blood (LTOWB) is being increasingly used for resuscitation of hemorrhagic shock in military and civilian settings. The objective of this study was to identify the impact of prehospital LTOWB on survival for patients in shock receiving prehospital LTOWB transfusion. STUDY DESIGN AND METHODS: A single institutional trauma registry was queried for patients undergoing prehospital transfusion between 2015 and 2019. Patients were stratified based on prehospital LTOWB transfusion (PHT) or no prehospital transfusion (NT). Outcomes measured included emergency department (ED), 6-h and hospital mortality, change in shock index (SI), and incidence of massive transfusion. Statistical analyses were performed. RESULTS: A total of 538 patients met inclusion criteria. Patients undergoing PHT had worse shock physiology (median SI 1.25 vs. 0.95, p < .001) with greater reversal of shock upon arrival (-0.28 vs. -0.002, p < .001). In a propensity-matched group of 214 patients with prehospital shock, 58 patients underwent PHT and 156 did not. Demographics were similar between the groups. Mean improvement in SI between scene and ED was greatest for patients in the PHT group with a lower trauma bay mortality (0% vs. 7%, p = .04). No survival benefit for patients in prehospital cardiac arrest receiving LTOWB was found (p > .05). DISCUSSION: This study demonstrated that trauma patients who received prehospital LTOWB transfusion had a greater improvement in SI and a reduction in early mortality. Patient with prehospital cardiac arrest did not have an improvement in survival. These findings support LTOWB use in the prehospital setting. Further multi-institutional prospective studies are needed.

Give the trauma patient what they bleed, when and where they need it: establishing a comprehensive regional system of resuscitation based on patient need utilizing cold-stored, low-titer O+ whole blood.

BACKGROUND: Despite countless advancements in trauma care a survivability gap still exists in the prehospital setting. Military studies clearly identify hemorrhage as the leading cause of potentially survivable prehospital death. Shifting resuscitation from the hospital to the point of injury has shown great promise in decreasing mortality among the severely injured. MATERIALS AND METHODS: Our regional trauma network (Southwest Texas Regional Advisory Council) developed and implemented a multiphased approach toward facilitating remote damage control resuscitation. This approach required placing low-titer O+ whole blood (LTO+ WB) at helicopter emergency medical service bases, transitioning hospital-based trauma resuscitation from component therapy to the use of whole blood, modifying select ground-based units to carry and administer whole blood at the scene of an accident, and altering the practices of our blood bank to support our new initiative. In addition, we had to provide information and training to an entire large urban emergency medical system regarding changes in policy. RESULTS: Through a thorough, structured program we were able to successfully implement point-of-injury resuscitation with LTO+ WB. Preliminary evaluation of our first 25 patients has shown a marked decrease in mortality compared to our historic rate using component therapy or crystalloid solutions. Additionally, we have had zero transfusion reactions or seroconversions. CONCLUSION: Transfusion at the scene within minutes of injury has the potential to save lives. As our utilization expands to our outlying network we expect to see a continued decrease in mortality among significantly injured trauma patients.

Removing the barriers to prehospital blood: a roadmap to success.

ABSTRACT: This review describes the necessity, evolution, and current state of prehospital blood programs in the United States. Less than 1% of 9-1-1 Ground Emergency Medical Service agencies have been able to successfully implement prehospital blood transfusions as part of a resuscitation strategy for patients in hemorrhagic shock despite estimates that annually between 54,000 and 900,000 patients may benefit from its use. The use of prehospital blood transfusions as a tool for managing hemorrhagic shock has barriers to overcome to ensure it becomes widely available to patients throughout the United States. Barriers include 1) current state Emergency Medical Services clinicians' scope of practice limitations, 2) program costs and reimbursement of blood products, 3) no centralized data collection process for prehospital hemorrhagic shock and patient outcomes, 4) collaboration between prehospital agencies, blood suppliers, and hospital clinicians and transfusion service activities. The following paper identifies barriers and a proposed roadmap to reduce death due to prehospital hemorrhage.

Prehospital Tourniquet Usage and Diabetes Mellitus Associated with Increased Incidence, Odds, and Risk of Acute Kidney Injury: A Pilot Study.

INTRODUCTION: Tourniquets are the standard of care for civilian and military prehospital treatment of massive extremity hemorrhages. Over the past 17 years, multiple military studies have demonstrated rare complications related to tourniquet usage. These studies may not translate well to civilian populations due to differences in baseline health. Experimental studies have demonstrated increased rates of post-traumatic acute kidney injuries (AKIs) in rats with obesity and increased oxidative stress, suggesting that comorbidities may affect AKI incidence with tourniquet usage. Two recently published retrospective studies, focused on the safety of tourniquets deployed within civilian sectors, documented increased incidence of AKI in patients with a prehospital tourniquet as compared to previously published military results. This study aimed to provide descriptive data concerning the association between the use of prehospital tourniquets and AKIs amongst civilian patient populations as AKIs increase mortality in hospitalized patients. METHODS: This was a single-center, observational, cross-sectional, pilot study involving chart review of participants presenting to a tertiary Level 1 trauma center. Patient data were extracted from prehospital and hospital electronic medical records. For this study, AKI was defined using the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines. RESULTS: A total of 255 participants were included. Participants with a history of diabetes mellitus had a significantly higher incidence of AKI as compared to those without. Analysis revealed an increased odds of AKI with diabetes in association to the use of a prehospital tourniquet. Participants with diabetes had an increased relative risk of AKI in association to the use of a prehospital tourniquet. The incidence of AKI was statistically higher than what was previous reported in the military population in association with the use of a prehospital tourniquet. CONCLUSION: The incidence of AKIs was higher than previously reported. Patients with diabetes had an associated higher risk and incidence of sustaining an AKI after the use of a prehospital tourniquet in association with the use of a prehospital tourniquet. This may be due to the known deleterious effects of diabetes mellitus on renal function. This study provides clinically relevant data that warrant further multi-site investigations to further investigate this study's associated findings and potential causation. It also stresses the need to assess whether renally-impacting environmental and nutritional stressors affect AKI rates amongst military personnel and others in which prehospital tourniquets are used.

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

INTRODUCTION: 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. MATERIALS AND METHODS: 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. RESULTS: 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. DISCUSSION: 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.

Prehospital shock index and systolic blood pressure are highly specific for pediatric massive transfusion.

BACKGROUND: While massive transfusion protocols (MTPs) are associated with decreased mortality in adult trauma patients, there is limited research on the impact of MTP on pediatric trauma patients. The purpose of this study was to compare pediatric trauma patients requiring massive transfusion with all other pediatric trauma patients to identify triggers for MTP activation in injured children. METHODS: Using our level I trauma center's registry, we retrospectively identified all pediatric trauma patients from January 2015 to January 2018. Massive transfusion (MT) was defined as infusion of 40 mL/kg of blood products in the first 24 hours of admission. Patients missing prehospital vital sign data were excluded from the study. We retrospectively collected data including demographics, blood utilization, variable outcome data, prehospital vital signs, prehospital transport times, and Injury Severity Scores. Statistical significance was determined using Mann-Whitney U test and χ2 test. p Values of less than 0.05 were considered significant. RESULTS: Thirty-nine (1.9%) of the 2,035 pediatric patients met the criteria for MT. All-cause mortality in MT patients was 49% (19 of 39 patients) versus 0.01% (20 of 1996 patients) in non-MT patients. The two groups significantly differed in Injury Severity Score, prehospital vital signs, and outcome data.Both systolic blood pressure (SBP) of <100 mm Hg and shock index (SI) of >1.4 were found to be highly specific for MT with specificities of 86% and 92%, respectively. The combination of SBP of <100 mm Hg and SI of >1.4 had a specificity of 94%. The positive and negative predictive values of SBP of <100 mm Hg and SI of >1.4 in predicting MT were 18% and 98%, respectively. Based on positive likelihood ratios, patients with both SBP of <100 mm Hg and SI of >1.4 were 7.2 times more likely to require MT than patients who did not meet both of these vital sign criteria. CONCLUSION: Pediatric trauma patients requiring early blood transfusion present with lower blood pressures and higher heart rates, as well as higher SIs and lower pulse pressures. We found that SI and SBP are highly specific tools with promising likelihood ratios that could be used to identify patients requiring early transfusion. LEVEL OF EVIDENCE: Therapeutic/care management, level V.