Mass casualty events: blood transfusion emergency preparedness across the continuum of care

Prehospital Lessons From the War in Ukraine: Damage Control Resuscitation and Surgery Experiences From Point of Injury to Role 2

The ongoing war in Ukraine presents unique challenges to prehospital medical care for wounded combatants and civilians. The purpose of this article is to identify, describe, and address gaps in prehospital care, casualty evacuation, and medical evacuation throughout Ukraine to share lessons for other providers. Observations and experiences of medical personnel were collected and analyzed, focusing on pain management, antibiotic use, patient assessment, mass casualty triage, blood loss, hypothermia, transport immobilization, and clinical governance. Gaps identified include limited access to pain management, lack of antibiotic guidance, inadequate patient assessment and triage, access to damage control resuscitation and blood, challenged transport immobilization practices, and challenges with clinical governance for both local and foreign providers. Improved prehospital care and casualty and medical evacuation in Ukraine are required, through increased use of empiric pain management, focused antibiotic guidance, enhanced patient assessment and triage in the form of training, access to prehospital blood, and better transport immobilization practices. A robust and active lessons learned program, trauma data capture, and quality improvement process is needed to reduce preventable morbidity and mortality in the war zone. The recommendations presented in this article serve as a starting point for improvements in prehospital care in Ukraine with potential to change prehospital training for the NATO alliance and other organizations operating in similar areas of conflict. Graphical Abstract.

Optimizing Mass Casualty Triage: Using Discrete Event Simulation to Minimize Time to Resuscitation

BACKGROUND

Urban areas in the US are increasingly focused on mass casualty incident (MCI) response. We simulated prehospital triage scenarios and hypothesized that using hospital-based blood product inventories for on-scene triage decisions would minimize time to treatment.

STUDY DESIGN

Discrete event simulations modeled MCI casualty injury and patient flow after a simulated blast event in Boston, MA. Casualties were divided into moderate (Injury Severity Score 9 to 15) and severe (Injury Severity Score >15) based on injury patterns. Blood product inventories were collected from all hospitals (n = 6). The primary endpoint was the proportion of casualties managed with 1:1:1 balanced resuscitation in a target timeframe (moderate, 3.5 U red blood cells in 6 hours; severe, 10 U red blood cells in 1 hour). Three triage scenarios were compared, including unimpeded casualty movement to proximate hospitals (Nearest), equal distribution among hospitals (Equal), and blood product inventory-based triage (Supply-Guided).

RESULTS

Simulated MCIs generated a mean ± SD of 302 ± 7 casualties, including 57 ± 2 moderate and 15 ± 2 severe casualties. Nearest triage resulted in significantly fewer overall casualties treated in the target time (55% vs Equal 86% vs Supply-Guided 91%, p < 0.001). These differences were principally due to fewer moderate casualties treated, but there was no difference among strategies for severe casualties.

CONCLUSIONS

In this simulation study comparing different triage strategies, including one based on actual blood product inventories, nearest hospital triage was inferior to equal distribution or a Supply-Guided strategy. Disaster response leaders in US urban areas should consider modeling different MCI scenarios and casualty numbers to determine optimal triage strategies for their area given hospital numbers and blood product availability.

Training of medical students in the use of emergency whole blood collection and transfusion in the framework of a civilian walking blood

INTRODUCTION

In this report, we describe a training program in emergency whole blood collection and transfusion for medical students at the University of Bergen. The overall aim of the program is to improve the availability of early balanced blood transfusion for the treatment of patients with life-threatening bleeding in rural health care services.

STUDY DESIGN AND METHODS

The voluntary training program provides the knowledge needed to practice emergency whole blood transfusions and understand the system for emergency whole blood collection in the framework of a civilian walking blood bank (WBB). It includes theoretical and practical sessions. In-person teaching and web-based learning resources are provided. An anonymous survey of the students attending the training course in the autumn of 2022 and spring 2023 was performed.

RESULTS

128 of 178 students participated in the practical training. 88 of 128 (69%) responded to the survey. 82 (93%) performed blood typing, 71 (81%) performed donor interviews, 61 (69%) partially performed whole blood collection (up to blood in bag) and 27 (30%) participated in complete whole blood collection and performed autologous reinfusion. No complications occurred during training. The students reported that the training course increased their understanding of how to ensure access to emergency blood transfusion by the use of a WBB.

DISCUSSION

Structured theoretical and practical training in emergency whole blood collection and emergency transfusion is feasible and of interest to medical students. A multidisciplinary approach to student training in emergency whole blood collection and transfusion should be considered.

The Norwegian blood preparedness project: A whole blood program including civilian walking blood banks for early treatment of patients with life-threatening bleeding in municipal health care services, ambulance services, and rural hospitals

Background

Civilian and military guidelines recommend early balanced transfusion to patients with life‐threatening bleeding to improve survival. To provide the best care to patients with hemorrhagic shock in regions with reduced access to evacuation, blood preparedness must be ensured also on a municipal health care level. The primary aim of the Norwegian Blood Preparedness project is to enable rural hospitals, prehospital ambulance services, and municipal health care services to start early balanced blood transfusions for patients with life‐threatening bleeding regardless of etiology.

Study Design and Methods

The project is designed based on three principles: (1) Early balanced transfusion should be provided for patients with life‐threatening bleeding, (2) Management of an emergency requires a planned and rehearsed day‐to‐day system for blood preparedness, and (3) A decentralized system is needed to ensure local self‐sufficiency in an emergency. We developed a system for education and training in blood‐based resuscitation with a focus on the municipal health care service.

Results

In this publication, we describe the implementation of emergency whole blood collections from a preplanned civilian walking blood bank in the municipal health care service. This includes donor selection, whole blood collection, emergency transfusion and quality assessment of practice.

Conclusion

We conclude that implementation of a Whole Blood based emergency transfusion program is feasible on all health care levels and that a preplanned civilian walking blood bank should be considered in locations were prolonged transport‐times may reduce access to blood transfusion for patients with life threatening bleeding.

U.S. cities will not meet blood product resuscitation standards during major mass casualty incidents: Results of a THOR-AABB working party prospective analysis

BACKGROUND

Mass casualty incidents (MCIs) create an immediate surge in blood product demand. We hypothesize local inventories in major U.S. cities would not meet this demand.

STUDY DESIGN AND METHODS

A simulated blast in a large crowd estimated casualty numbers. Ideal resuscitation was defined as equal amounts of red blood cells (RBCs), plasma, platelets, and cryoprecipitate. Inventory was prospectively collected from six major U.S. cities at six time points between January and July 2019. City-wide blood inventories were classified as READY (>1 U/injured survivor), DEFICIENT (<10 U/severely injured survivor), or RISK (between READY and DEFICIENT), before and after resupply from local distribution centers (DC), and features of DEFICIENT cities were identified.

RESULTS

The simulated blast resulted in 2218 injured survivors including 95 with severe injuries. Balanced resuscitation would require between 950 and 2218 units each RBC, plasma, platelets and cryoprecipitate. Inventories in 88 hospitals/health systems and 10 DCs were assessed. Of 36 city-wide surveys, RISK inventories included RBCs (n = 16; 44%), plasma (n = 24; 67%), platelets (n = 6; 17%), and cryoprecipitate (n = 22; 61%) while DEFICIENT inventories included platelets (n = 30; 83%) and cryoprecipitate (n = 12; 33%). Resupply shifted most RBC and plasma inventories to READY, but some platelet and cryoprecipitate inventories remained at RISK (n = 24; 67% and n = 12; 33%, respectively) or even DEFICIENT (n = 11; 31% and n = 6; 17%, respectively). Cities with DEFICIENT inventories were smaller (p <.001) with fewer blood products per trauma bed (p <.001).

DISCUSSION

In this simulated blast event, blood product demand exceeded local supply in some major U.S. cities. Options for closing this gap should be explored to optimize resuscitation during MCIs.

Maintaining adequate donations and a sustainable blood supply: Lessons learned

Background

The availability of a safe blood supply is a key component of transfusion medicine. A decade of decreased blood use, decreased payment for products, and a dwindling donor base have placed the sustainability of the US blood supply at risk.

Study Design and Methods

A literature review was performed for blood center (BC) and hospital disaster management, chronically transfusion‐dependent diseases, and appropriate use of group O‐negative red blood cells (RBCs), and the Choosing Wisely campaign. The aim was to identify current practice and to make recommendations for BC and hospital actions.

Results

While BCs are better prepared to handle disasters than after the 9/11 attacks, messaging to the public remains difficult, as donors often do not realize that blood transfused during a disaster was likely collected before the event. BCs and transfusion services should participate in drafting disaster response plans. Hospitals should maintain inventories adequate for patients in the event supply is disrupted. Providing specialty products for transfusion‐dependent patients can strain collections, lead to increased use of group O RBCs, and create logistical inventory challenges for hospitals. The AABB Choosing Wisely initiative addresses overuse of blood components to optimally use this precious resource. Group O‐negative RBCs should be transfused only to patients who truly need them.

Conclusions

Collecting and maintaining a blood supply robust enough to handle disasters and transfusion‐dependent patients in need of specialty products is challenging. Collaboration of all parties should help to optimize resources, ensure appropriate collections, improve patient care, and ultimately result in a robust, sustainable blood supply.

Potential challenges faced by blood bank services during COVID-19 pandemic and their mitigative measures: The Indian scenario

The current pandemic caused by SARS-CoV-2 virus is going to be a prolonged melee. Identifying crucial areas, proactive planning, coordinated strategies and their timely implication is essential for smooth functioning of any system during a crunch. Addressing the impact of COVID-19 on transfusion services, there are 4 potential challenges viz. blood/ component shortage, donor/ staff safety, consumable supply/ logistics and catering to the convalescent plasma need. In this review article, we will be discussing about these potential challenges in detail along with the necessary mitigative steps to be adopted to tide over the COVID-19 crisis in an Indian set up.

From battlefront to homefront: creation of a civilian walking blood bank

Hemorrhagic shock remains the leading cause of preventable death on the battlefield, despite major advances in trauma care. Early initiation of balanced resuscitation has been shown to decrease mortality in the hemorrhaging patient. To address transfusion limitations in austere environments or in the event of multiple casualties, walking blood banks have been used in the combat setting with great success. Leveraging the success of the region-wide whole blood program in San Antonio, Texas, we report a novel plan that represents a model response to mass casualty incidents.

CE: A Review of Current Practice in Transfusion Therapy

: In the United States, roughly 4.5 million patients per year receive transfusions of various blood products. Despite the lifesaving benefits of transfusion therapy, it is an independent risk factor for infection, morbidity, and death in critically ill patients. It's important for nurses to understand the potential complications patients face when blood products are administered and to recognize that patients who have received blood products in the past remain at risk for delayed reactions, including immune compromise and infection. Here, the authors review the blood products that are commonly transfused; discuss potential complications of transfusion, as well as their associated signs and symptoms; and outline current recommendations for transfusion therapy that are widely supported in the medical and nursing literature.

Research of an emergency medical system for mass casualty incidents in Shanghai, China: a system dynamics model

OBJECTIVES

Emergency medical system for mass casualty incidents (EMS-MCIs) is a global issue. However, China lacks such studies extremely, which cannot meet the requirement of rapid decision-support system. This study aims to realize modeling EMS-MCIs in Shanghai, to improve mass casualty incident (MCI) rescue efficiency in China, and to provide a possible method of making rapid rescue decisions during MCIs.

METHODS

This study established a system dynamics (SD) model of EMS-MCIs using the Vensim DSS program. Intervention scenarios were designed as adjusting scales of MCIs, allocation of ambulances, allocation of emergency medical staff, and efficiency of organization and command.

RESULTS

Mortality increased with the increasing scale of MCIs, medical rescue capability of hospitals was relatively good, but the efficiency of organization and command was poor, and the prehospital time was too long. Mortality declined significantly when increasing ambulances and improving the efficiency of organization and command; triage and on-site first-aid time were shortened if increasing the availability of emergency medical staff. The effect was the most evident when 2,000 people were involved in MCIs; however, the influence was very small under the scale of 5,000 people.

CONCLUSION

The keys to decrease the mortality of MCIs were shortening the prehospital time and improving the efficiency of organization and command. For small-scale MCIs, improving the utilization rate of health resources was important in decreasing the mortality. For large-scale MCIs, increasing the number of ambulances and emergency medical professionals was the core to decrease prehospital time and mortality. For super-large-scale MCIs, increasing health resources was the premise.

Blood component transfusions in mass casualty events

BACKGROUND AND OBJECTIVES

Planning transfusion needs in mass casualty events (MCE) is critical for disaster preparedness. Published data on blood component usage were analysed to seek correlative factors and usage rates.

MATERIALS AND METHODS

English-language medical publications since 1980 were searched for MCEs with numbers of patient admissions and transfused RBCs. Reports were excluded from natural disasters or with total RBC use <50 units. Statistical analysis employed Mann-Whitney U-tests and Spearman's rank correlations.

RESULTS

In 24 reports, the average units per admission were 3·06 RBCs, 2·13 plasmas and 0·37 platelet doses. Five RBCs per admission would have sufficed for 87% of events. Transfusion needs involving bombings correlated with admissions (P ≤ 0·03). In the formula (massive-transfusion patients in MCE) times X = (total units for all MCE patients), the average X was 35 for RBCs (correlation P = 0·01), 17 for plasma (P = 0·10) and five for platelet doses (P = 0·06). From 67% to 84% of all components used were given in the first 24 h (event medians).

CONCLUSIONS

Blood component use in MCEs correlated with numbers of patients admitted or receiving massive transfusion. More current data are needed to better reflect emerging trauma care practices and refine predictive models of transfusion needs.