The impact of prehospital whole blood on hemorrhaging trauma patients: A multi-center retrospective study.

BACKGROUND: Whole blood (WB) use has become increasingly common in trauma centers across the United States for both in-hospital and prehospital resuscitation. We hypothesize that prehospital WB (pWB) use in trauma patients with suspected hemorrhage will result in improved hemodynamic status and reduced in-hospital blood product requirements. METHODS: The institutional trauma registries of two academic level I trauma centers were queried for all patients from 2015-2019 who underwent transfusion upon arrival to the trauma bay. Patients who were dead on arrival or had isolated head injuries were excluded. Demographics, injury and shock characteristics, transfusion requirements, including massive transfusion protocol (MTP) (>10 U in 24 hours) and rapid transfusion (CAT3+) and outcomes were compared between pWB and non-pWB patients. Significantly different demographic, injury characteristics and pWB were included in univariate followed by stepwise logistic regression analysis to determine the relationship with shock index (SI). Our primary objective was to determine the relationship between pWB and improved hemodynamics or reduction in blood product utilization. RESULTS: A total of 171 pWB and 1391 non-pWB patients met inclusion criteria. Prehospital WB patients had a lower median Injury Severity Score (17 vs. 21, p < 0.001) but higher prehospital SI showing greater physiologic disarray. Prehospital WB was associated with improvement in SI (-0.04 vs. 0.05, p = 0.002). Mortality and (LOS) were similar. Prehospital WB patients received fewer packed red blood cells, fresh frozen plasma, and platelets units across their LOS but total units and volumes were similar. Prehospital WB patients had fewer MTPs (22.6% vs. 32.4%, p = 0.01) despite a similar requirement of CAT3+ transfusion upon arrival. CONCLUSION: Prehospital WB administration is associated with a greater improvement in SI and a reduction in MTP. This study is limited by its lack of power to detect a mortality difference. Prospective randomized controlled trials will be required to determine the true impact of pWB on trauma patients. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

The regional whole blood program in San Antonio, TX: A 3-year update on prehospital and in-hospital transfusion practices for traumatic and non-traumatic hemorrhage.

Low titer type O Rh-D + whole blood (LTO + WB) has become a first-line resuscitation medium for hemorrhagic shock in many centers around the World. Showing early effectiveness on the battlefield, LTO + WB is used in both the pre-hospital and in-hospital settings for traumatic and non-traumatic hemorrhage resuscitation. Starting in 2018, the San Antonio Whole Blood Collaborative has worked to provide LTO + WB across Southwest Texas, initially in the form of remote damage control resuscitation followed by in-hospital trauma resuscitation. This program has since expanded to include pediatric trauma resuscitation, obstetric hemorrhage, females of childbearing potential, and non-traumatic hemorrhage. The objective of this manuscript is to provide a three-year update on the successes and expansion of this system and outline resuscitation challenges in special populations.

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.

Follow-Up Evaluation of the U.S. Army Institute of Surgical Research Burn Flow Sheet for En Route Care Documentation of Burned Combat Casualties.

INTRODUCTION: In 2006, burn clinical practice guidelines were developed to provide recommendations for optimal care of U.S. military and local national burn casualties. As part of that effort, a paper-based Burn Flow Sheet (BFS) was included to document the burn resuscitation of combat casualties with ≥20% total body surface area burns. The purpose of this study was to evaluate the BFS in terms of ongoing utilization, resuscitation management, and outcomes of patients transported. MATERIALS AND METHODS: A retrospective review was performed of hard-copy BFSs received from January 2007 to December 2013. En route injury and treatment data from these flowsheets were manually transcribed into the research database. Outcomes and complications of BFS subjects were extracted from the Burn Center Registry and added to the research database. RESULTS: A total of 73 BFSs were collected from the study period. On average, BFSs were 61 ± 30% complete with a total of 14.7 ± 7 hours documented per patient in the first 24-hours postburn. Patients received nearly 7 L more fluid than estimated by traditional formulas. Sixteen patients (26%) received greater than 250 mL/kg of fluid, half of whom had concomitant traumatic injuries. Fifteen patients received a fasciotomy (21%), 4 received a laparotomy (5%), and 8 (11%) received both. No patients developed abdominal compartment syndrome associated with fluid resuscitation. Overall mortality was 21%. CONCLUSIONS: Although the majority of providers did initiate a BFS, it was not always used as intended; problems included missing data and miscalculations. Although there was a clear improvement with decline in the incidence of abdominal compartment syndrome, mortality did not change for severely burned patients. Simplification of the recommendations, additional built-in prompts, and automated tools such as computerized decision support software may help standardize practice and improve outcomes.

Intercontinental distribution of a new trypanosome species from Australian endemic Regent Honeyeater (Anthochaera phrygia).

Establishing a health screening protocol is fundamental for successful captive breeding and release of wildlife. The aim of this study was to undertake a parasitological survey focusing on the presence of trypanosomes in a cohort of Regent Honeyeaters, Anthochaera phrygia, syn. Xanthomyza phrygia (Aves: Passeriformes) that are part of the breeding and reintroduction programme carried out in Australia. We describe a new blood parasite, Trypanosoma thomasbancrofti sp. n. (Kinetoplastida: Trypanosomatidae) with prevalence of 24·4% (20/81) in a captive population in 2015. The sequence of the small subunit rRNA gene (SSU rDNA) and kinetoplast ultrastructure of T. thomasbancrofti sp. n. are the key differentiating characteristics from other Trypanosoma spp. T. thomasbancrofti sp. n. is distinct from Trypanosoma cf. avium found in sympatric Noisy Miners (Manorina melanocephala). The SSU rDNA comparison suggests an intercontinental distribution of T. thomasbancrofti sp. n. and Culex mosquitoes as a suspected vector. Currently, no information exists on the effect of T. thomasbancrofti sp. n. on its hosts; however, all trypanosome-positive birds remain clinically healthy. This information is useful in establishing baseline health data and screening protocols, particularly prior to release to the wild.

Afternoon shedding of a new species of Isospora (Apicomplexa) in the endangered Regent Honeyeater (Xanthomyza phrygia).

The Regent Honeyeater (Xanthomyza phyrigia) is an endangered Australian bird species. Breeding populations have been established at Australian zoos in support of re-introduction programmes. This species is the host of a new species of Isospora (Apicomplexa). Oocysts are spherical, 25·8 (22·5-28·75) by 23·8 (20-26·25) µm with a colourless to pale yellow smooth wall undergoing rapid exogenous sporulation, 90% sporulated oocysts in 8 h at 20°C. Each oocyst contains 1 polar granule. Sporocysts are ovoid, 18·67 (17-19) by 9·49 (9-10) µm with a flat Stieda body and spherical substieda body devoid of a hyaline body. The asexual stages and sexual phase is within the enterocytes of the duodenum and jejunum. Faeces collected in the morning (AM, n=84) and in the afternoon (PM, n=90) revealed significant diurnal periodicity in oocyst shedding; 21% (18 of 84) of the AM were positive with the mean of 499 oocysts.g-1 compared to the PM with 91% (82 of 90) bird faeces positive with the mean of 129 723 oocysts.g-1. Therefore, parasite checks for these birds should be carried out in the afternoon to obtain an accurate result. The ecological significance of the high parasite burden in captive birds requires further investigation and comparison to the wild counterparts.