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McCartin MP, Wool GD, Thomas SA, Panfil M, Schoenfeld D, Blumen IJ, Tataris KL, Thomas SH. Management Considerations for Air Medical Transport Programs Transfusing RhD-Positive Red Blood Cell-Containing Products to Females of Childbearing Potential. Air Med J 2024; 43:348-356. [PMID: 38897700 DOI: 10.1016/j.amj.2024.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Revised: 03/11/2024] [Accepted: 03/21/2024] [Indexed: 06/21/2024]
Abstract
Recent years have seen increased discussion surrounding the benefits of damage control resuscitation, prehospital transfusion (PHT) of blood products, and the use of whole blood over component therapy. Concurrent shortages of blood products with the desire to provide PHT during air medical transport have prompted reconsideration of the traditional approach of administering RhD-negative red cell-containing blood products first-line to females of childbearing potential (FCPs). Given that only 7% of the US population has blood type O negative and 38% has O positive, some programs may be limited to offering RhD-positive blood products to FCPs. Adopting the practice of giving RhD-positive blood products first-line to FCPs extends the benefits of PHT to such patients, but this practice does incur the risk of future hemolytic disease of the fetus and newborn (HDFN). Although the risk of future fetal mortality after an RhD-incompatible transfusion is estimated to be low in the setting of acute hemorrhage, the number of FCPs who are affected by this disease will increase as more air medical transport programs adopt this practice. The process of monitoring and managing HDFN can also be time intensive and costly regardless of the rates of fetal mortality. Air medical transport programs planning on performing PHT of RhD-positive red cell-containing products to FCPs should have a basic understanding of the pathophysiology, prevention, and management of hemolytic disease of the newborn before introducing this practice. Programs should additionally ensure there is a reliable process to notify receiving centers of potentially RhD-incompatible PHT because alloimmunization prophylaxis is time sensitive. Facilities receiving patients who have had PHT must be prepared to identify, counsel, and offer alloimmunization prophylaxis to these patients. This review aims to provide air medical transport professionals with an understanding of the pathophysiology and management of HDFN and provide a template for the early management of FCPs who have received an RhD-positive red cell-containing PHT. This review also covers the initial workup and long-term anticipatory guidance that receiving trauma centers must provide to FCPs who have received RhD-positive red cell-containing PHT.
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Affiliation(s)
| | | | - Sarah A Thomas
- Department of Molecular Microbiology and Immunology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | | | - David Schoenfeld
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Ira J Blumen
- Section of Emergency Medicine, University of Chicago, Chicago, IL
| | - Katie L Tataris
- Section of Emergency Medicine, University of Chicago, Chicago, IL
| | - Stephen H Thomas
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA; Blizard Institute for Neuroscience, Surgery, and Trauma, Barts and The London School of Medicine, London, UK
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Facchetti G, Facchetti M, Schmal M, Lee R, Fiorelli S, Marzano TF, Lupi C, Daminelli F, Sbrana G, Massullo D, Marinangeli F. Prehospital Blood Transfusion in Helicopter Emergency Medical Services: An Italian Survey. Air Med J 2024; 43:140-145. [PMID: 38490777 DOI: 10.1016/j.amj.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 10/17/2023] [Accepted: 11/12/2023] [Indexed: 03/17/2024]
Abstract
OBJECTIVE Hemorrhage remains the most common cause of preventable death after trauma. Prehospital blood product (PHBP) administration may improve outcomes. No data are available about PHBP use in Italian helicopter emergency medical services (HEMS). The primary aim of this survey was to establish the degree of PHBP used throughout Italy. The secondary aims were to evaluate the main indications for their use, the opinions about PHBPs, and users' experience. METHODS The study group performed a telephone/e-mail survey of all 56 Italian HEMS bases. The questions concerned whether PHBPs were used in their HEMS bases, the frequency of transfusions, the PHBP used, and the perceived benefits. RESULTS Four of 56 HEMS bases use PHBPs. Overall, 7% have prehospital access to packed red cells and only 1 to fresh plasma. In addition to blood product administration, 4 of 4 use tranexamic acid, and 3 of 4 also use fibrinogen. Seventy-five percent use PHBPs once a month and 25% once a week. The users' experience was that PHBPs are beneficial and lifesaving. CONCLUSION Only 4 of 56 HEMS in Italy use PHBPs. There is an absolute consensus among providers on the benefit of PHBPs despite the lack of evidence on PHBP use.
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Affiliation(s)
| | - Marilisa Facchetti
- Department Anesthesiology and Critical Care, University of L'Aquila, L'Aquila, Italy
| | - Mariette Schmal
- Jeugdgezondheidszorg Zuid-Holland West, Zoetermeer, Netherlands
| | - Ronan Lee
- European Patent Office, Team Surgery, Rijswijk, Netherlands
| | - Silvia Fiorelli
- Anesthesia and Intensive Care Medicine, Department of Clinical and Surgical Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy.
| | | | - Cristian Lupi
- HEMS Bologna, Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Azienda Unità Sanitaria Locale Bologna, Bologna, Italy
| | - Francesco Daminelli
- HEMS Bergamo, Papa Giovanni XXIII Hospital, Agenzia Regionale Emergenza Urgenza Lombardia, Bergamo, Italy
| | - Giovanni Sbrana
- HEMS Grosseto, Emergency Department, Azienda Sanitaria Locale Toscana Sud Est, Grosseto, Italy
| | - Domenico Massullo
- Anesthesia and Intensive Care Medicine, Department of Clinical and Surgical Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Franco Marinangeli
- Department Anesthesiology and Critical Care, University of L'Aquila, L'Aquila, Italy
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Blais-Normandin I, Rymer T, Feenstra S, Burry A, Colavecchia C, Duncan J, Farrell M, Greene A, Gupta A, Huynh Q, Lawrence R, Lehto P, Lett R, Lin Y, Lyon B, McCarthy J, Nahirniak S, Nolan B, Peddle M, Prokopchuk-Gauk O, Sham L, Trojanowski J, Shih AW. Current state of technical transfusion medicine practice for out-of-hospital blood transfusion in Canada. Vox Sang 2023; 118:1086-1094. [PMID: 37794849 DOI: 10.1111/vox.13542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 09/11/2023] [Accepted: 09/18/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND AND OBJECTIVES Canadian out-of-hospital blood transfusion programmes (OHBTPs) are emerging, to improve outcomes of trauma patients by providing pre-hospital transfusion from the scene of injury, given prolonged transport times. Literature is lacking to guide its implementation. Thus, we sought to gather technical transfusion medicine (TM)-specific practices across Canadian OHBTPs. MATERIALS AND METHODS A survey was sent to TM representatives of Canadian OHBTPs from November 2021 to March 2022. Data regarding transport, packaging, blood components and inventory management were included and reported descriptively. Only practices involving Blood on Board programme components for emergency use were included. RESULTS OHBTPs focus on helicopter emergency medical service programmes, with some supplying fixed-wing aircraft and ground ambulances. All provide 1-3 coolers with 2 units of O RhD/Kell-negative red blood cells (RBCs) per cooler, with British Columbia trialling coolers with 2 units of pre-thawed group A plasma. Inventory exchanges are scheduled and blood components are returned to TM inventory using visual inspection and internal temperature data logger readings. Coolers are validated to storage durations ranging from 72 to 124 h. All programmes audit to manage wastage, though there is no consensus on appropriate benchmarks. All programmes have a process for documenting units issued, reconciliation after transfusion and for transfusion reaction reporting; however, training programmes vary. Common considerations included storage during extreme temperature environments, O-negative RBC stewardship, recipient notification, traceability, clinical practice guidelines co-reviewed by TM and a common audit framework. CONCLUSION OHBTPs have many similarities throughout Canada, where harmonization may assist in further developing standards, leveraging best practice and national coordination.
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Affiliation(s)
- Isabelle Blais-Normandin
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Tihiro Rymer
- Alberta Precision Labs, Transfusion and Transplantation Medicine, Edmonton, Alberta, Canada
| | - Shelley Feenstra
- Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada
| | - Anne Burry
- Alberta Precision Labs, Transfusion and Transplantation Medicine, Edmonton, Alberta, Canada
| | | | - Jennifer Duncan
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Vancouver Island Health Authority, Courtenay, British Columbia, Canada
| | - Michael Farrell
- Provincial Blood Coordinating Team, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Adam Greene
- British Columbia Emergency Health Services, Parksville, British Columbia, Canada
| | - Akash Gupta
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Queenie Huynh
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Robin Lawrence
- Saskatchewan Health Authority, Regina, Saskatchewan, Canada
| | - Paula Lehto
- Saskatchewan Health Authority, Saskatoon, Saskatchewan, Canada
| | - Ryan Lett
- Saskatchewan Health Authority, Regina, Saskatchewan, Canada
- Department of Anesthesiology, Regina, Saskatchewan, Canada
| | - Yulia Lin
- Vancouver Island Health Authority, Courtenay, British Columbia, Canada
- Saskatchewan Health Authority, Regina, Saskatchewan, Canada
| | - Bruce Lyon
- Alberta Precision Labs, Transfusion and Transplantation Medicine, Edmonton, Alberta, Canada
| | - Joanna McCarthy
- Alberta Precision Labs, Transfusion and Transplantation Medicine, Edmonton, Alberta, Canada
| | - Susan Nahirniak
- Alberta Precision Labs, Transfusion and Transplantation Medicine, Edmonton, Alberta, Canada
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Brodie Nolan
- Provincial Blood Coordinating Team, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Emergency Medicine, Unity Health Toronto, Toronto, Ontario, Canada
| | - Michael Peddle
- Ornge, Mississauga, Ontario, Canada
- Division of Emergency Medicine, Western University, London, Ontario, Canada
| | - Oksana Prokopchuk-Gauk
- Saskatchewan Health Authority, Saskatoon, Saskatchewan, Canada
- Department of Pathology and Laboratory Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Lawrence Sham
- Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada
| | - Jan Trojanowski
- Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada
- Department of Emergency Medicine, Vancouver, British Columbia, Canada
- British Columbia Emergency Health Services, Vancouver, British Columbia, Canada
| | - Andrew W Shih
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada
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Smith JE, Barnard EBG, Brown-O'Sullivan C, Cardigan R, Davies J, Hawton A, Laing E, Lucas J, Lyon R, Perkins GD, Smith L, Stanworth SJ, Weaver A, Woolley T, Green L. The SWiFT trial (Study of Whole Blood in Frontline Trauma)-the clinical and cost effectiveness of pre-hospital whole blood versus standard care in patients with life-threatening traumatic haemorrhage: study protocol for a multi-centre randomised controlled trial. Trials 2023; 24:725. [PMID: 37964393 PMCID: PMC10644622 DOI: 10.1186/s13063-023-07711-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 10/06/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND Early blood transfusion improves survival in patients with life-threatening bleeding, but the optimal transfusion strategy in the pre-hospital setting has yet to be established. Although there is some evidence of benefit with the use of whole blood, there have been no randomised controlled trials exploring the clinical and cost effectiveness of pre-hospital administration of whole blood versus component therapy for trauma patients with life-threatening bleeding. The aim of this trial is to determine whether pre-hospital leukocyte-depleted whole blood transfusion is better than standard care (blood component transfusion) in reducing the proportion of participants who experience death or massive transfusion at 24 h. METHODS This is a multi-centre, superiority, open-label, randomised controlled trial with internal pilot and within-trial cost-effectiveness analysis. Patients of any age will be eligible if they have suffered major traumatic haemorrhage and are attended by a participating air ambulance service. The primary outcome is the proportion of participants with traumatic haemorrhage who have died (all-cause mortality) or received massive transfusion in the first 24 h from randomisation. A number of secondary clinical, process, and safety endpoints will be collected and analysed. Cost (provision of whole blood, hospital, health, and wider care resource use) and outcome data will be synthesised to present incremental cost-effectiveness ratios for the trial primary outcome and cost per quality-adjusted life year at 90 days after injury. We plan to recruit 848 participants (a two-sided test with 85% power, 5% type I error, 1-1 allocation, and one interim analysis would require 602 participants-after allowing for 25% of participants in traumatic cardiac arrest and an additional 5% drop out, the sample size is 848). DISCUSSION The SWiFT trial will recruit 848 participants across at least ten air ambulances services in the UK. It will investigate the clinical and cost-effectiveness of whole blood transfusion versus component therapy in the management of patients with life-threatening bleeding in the pre-hospital setting. TRIAL REGISTRATION ISRCTN: 23657907; EudraCT: 2021-006876-18; IRAS Number: 300414; REC: 22/SC/0072, 21 Dec 2021.
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Affiliation(s)
- Jason E Smith
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK.
- University Hospitals Plymouth NHS Trust, Plymouth, UK.
| | - Ed B G Barnard
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Rebecca Cardigan
- NHS Blood & Transplant, Bristol, UK
- Department of Haematology, University of Cambridge, Cambridge, UK
| | | | - Annie Hawton
- Health Economics Group, University of Exeter, Exeter, UK
| | - Emma Laing
- Intensive Care National Audit and Research Centre (ICNARC), London, UK
| | - Joanne Lucas
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Richard Lyon
- Air Ambulance Kent Surrey Sussex, Rochester, UK
- Department of Health Sciences, University of Surrey, Guildford, UK
| | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Laura Smith
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Simon J Stanworth
- NHS Blood & Transplant, Bristol, UK
- Oxford University Hospitals, Oxford, UK
- University of Oxford, Oxford, UK
| | - Anne Weaver
- London's Air Ambulance and Royal London Hospital, London, UK
| | - Tom Woolley
- Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, Birmingham, UK
| | - Laura Green
- NHS Blood & Transplant, Bristol, UK
- Barts Health NHS Trust, London, UK
- Queen Mary University of London, London, UK
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Certain L, Rostirola JVC, Rostirola GC, Pereira JS, Gonçalves I, Gabrigna KR, Speri FD, Mendes MF, Mottin TS, da Silva I, Rodrigues JA, Schevenin JDC, de Oliveira ABR, Franceli AB, Lisboa CEC, Benites BD. Prehospital blood transfusion in Brazil: results of the first year of implementation in an emergency medical service. Hematol Transfus Cell Ther 2023:S2531-1379(23)02534-8. [PMID: 37865550 DOI: 10.1016/j.htct.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 08/01/2023] [Accepted: 08/22/2023] [Indexed: 10/23/2023] Open
Abstract
INTRODUCTION Hemorrhagic shock is the main cause of death in the prehospital environment, which highlights the need to standardize measures aiming at bleeding control and volume replacement in this environment. In Brazil, the first prehospital packed red blood cell transfusion service started in September 2020, in Bragança Paulista, state of São Paulo. OBJECTIVES Describe the trends and characteristics of patients who received prehospital transfusions prior to hospital treatment during the first year of operation. METHODS A retrospective data review was made of all patients who received transfusions from the mobile intensive care unit in Bragança Paulista over one year. RESULTS In this period, 19 patients were transfused. Since activation, the average response time was 20 min. The mean shock indexes before and after blood transfusion were 2.16 and 1.1, respectively. During the course of the 1st year of prehospital transfusions, no blood was wasted and there were no adverse effects. CONCLUSION Introduction of the prehospital packed red blood cell transfusion service was successful, with significant improvement in hemodynamic parameters.
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Affiliation(s)
- Lucas Certain
- Serviço de Atendimento Móvel de Urgência (SAMU - 192), Bragança Paulista, SP, Brazil.
| | | | | | | | | | | | | | | | | | - Israel da Silva
- Serviço de Atendimento Móvel de Urgência (SAMU - 192), Bragança Paulista, SP, Brazil
| | | | | | | | | | | | - Bruno Deltreggia Benites
- Centro de Hematologia e Hemoterapia, Universidade Estadual de Campinas (Hemocentro Unicamp), Campinas, SP, Brazil
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Maegele M, Lier H, Hossfeld B. Pre-Hospital Blood Products for the Care of Bleeding Trauma Patients. DEUTSCHES ARZTEBLATT INTERNATIONAL 2023; 120:670-676. [PMID: 37551452 PMCID: PMC10644958 DOI: 10.3238/arztebl.m2023.0176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 07/13/2023] [Accepted: 07/13/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND Controversy surrounds the administration of blood products to severely traumatized patients before they arrive in the hospital in order to compensate for early blood loss and/or to correct coagulation disturbances that arise shortly after the traumatic event. A number of terrestrial and air rescue services have begun to provide this kind of treatment. METHODS This review is based on articles using the PICO framework, published from January 2001 to January 2021, that were retrieved by a selective search, with structured searching strategies and searching bundles in Medline (OVIDSP), the Cochrane Central Register of Controlled Trials (CENTRAL), and Epistemonikos. A demand analysis was carried out on the basis of data from the trauma registry of the German Society of Trauma Surgery (TR-DGU) and practical experience from program development and implementation was provided by the Bundeswehr Hospital Ulm. RESULTS The currently available evidence on the pre-hospital administration of blood products in the early treatment of severely injured patients is based largely on retrospective, single-center case series. Two randomized controlled trials (RCTs) concerning the early use of fresh frozen plasma concentrates have yielded partly conflicting results. Three further RCTs on the use of lyophilized plasma (lyplas), lyplas plus erythrocyte concentrate, or whole blood likewise revealed non-uniform effects on short-term and intermediate-term mortality. Our demand analysis based on data from the TR-DGU showed that 300 to 1800 patients per year in Germany could benefit from the pre-hospital administration of blood products. This might be indicated in patients who have systolic hypotension (<100 mmHg) in combination with a suspected or confirmed hemorrhage, as well as pathological shock parameters in the point-of-care diagnostic testing performed on the scene (serum base excess ≤ -2.5 mmol/L and/or serum lactate concentration >4 mmol/L). CONCLUSION The studies that have been published to date yield no clear evidence either for or against the early pre-hospital administration of blood products. Any treatment of this kind should be accompanied by scientific evaluation.
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Affiliation(s)
- Marc Maegele
- *Joint first authors
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Cologne
- Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Campus Cologne-Merheim, Cologne
| | - Heiko Lier
- *Joint first authors
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne
| | - Björn Hossfeld
- Department of Anaesthesiology and Intensive Care Medicine, Armed Forces Hospital Ulm, Ulm
- Rescue transport helicopter (RTH) „Christoph 22“ Ulm, ADAC-Air Rescue, Ulm
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Tucker H, Brohi K, Tan J, Aylwin C, Bloomer R, Cardigan R, Davenport R, Davies ED, Godfrey P, Hawes R, Lyon R, McCullagh J, Stanworth S, Thompson J, Uprichard J, Walsh S, Weaver A, Green L. Association of red blood cells and plasma transfusion versus red blood cell transfusion only with survival for treatment of major traumatic hemorrhage in prehospital setting in England: a multicenter study. Crit Care 2023; 27:25. [PMID: 36650557 PMCID: PMC9847037 DOI: 10.1186/s13054-022-04279-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 12/14/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND In-hospital acute resuscitation in trauma has evolved toward early and balanced transfusion resuscitation with red blood cells (RBC) and plasma being transfused in equal ratios. Being able to deliver this ratio in prehospital environments is a challenge. A combined component, like leukocyte-depleted red cell and plasma (RCP), could facilitate early prehospital resuscitation with RBC and plasma, while at the same time improving logistics for the team. However, there is limited evidence on the clinical benefits of RCP. OBJECTIVE To compare prehospital transfusion of combined RCP versus RBC alone or RBC and plasma separately (RBC + P) on mortality in trauma bleeding patients. METHODS Data were collected prospectively on patients who received prehospital transfusion (RBC + thawed plasma/Lyoplas or RCP) for traumatic hemorrhage from six prehospital services in England (2018-2020). Retrospective data on patients who transfused RBC from 2015 to 2018 were included for comparison. The association between transfusion arms and 24-h and 30-day mortality, adjusting for age, injury mechanism, age, prehospital heart rate and blood pressure, was evaluated using generalized estimating equations. RESULTS Out of 970 recruited patients, 909 fulfilled the study criteria (RBC + P = 391, RCP = 295, RBC = 223). RBC + P patients were older (mean age 42 vs 35 years for RCP and RBC), and 80% had a blunt injury (RCP = 52%, RBC = 56%). RCP and RBC + P were associated with lower odds of death at 24-h, compared to RBC alone (adjusted odds ratio [aOR] 0.69 [95%CI: 0.52; 0.92] and 0.60 [95%CI: 0.32; 1.13], respectively). The lower odds of death for RBC + P and RCP vs RBC were driven by penetrating injury (aOR 0.22 [95%CI: 0.10; 0.53] and 0.39 [95%CI: 0.20; 0.76], respectively). There was no association between RCP or RBC + P with 30-day survival vs RBC. CONCLUSION Prehospital plasma transfusion for penetrating injury was associated with lower odds of death at 24-h compared to RBC alone. Large trials are needed to confirm these findings.
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Affiliation(s)
- Harriet Tucker
- grid.4868.20000 0001 2171 1133Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT UK
| | - Karim Brohi
- grid.4868.20000 0001 2171 1133Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT UK ,grid.139534.90000 0001 0372 5777Barts Health NHS Trust, London, UK
| | - Joachim Tan
- grid.264200.20000 0000 8546 682XSt George’s University of London, London, UK
| | - Christopher Aylwin
- grid.426467.50000 0001 2108 8951St Mary’s Hospital, Imperial College NHS Foundation Trust, London, UK
| | - Roger Bloomer
- grid.429705.d0000 0004 0489 4320Kings College Hospital NHS Foundation Trust, London, UK
| | - Rebecca Cardigan
- grid.436365.10000 0000 8685 6563NHS Blood and Transplant, Cambridge, UK
| | - Ross Davenport
- grid.4868.20000 0001 2171 1133Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT UK ,grid.139534.90000 0001 0372 5777Barts Health NHS Trust, London, UK
| | - Edward D. Davies
- grid.416204.50000 0004 0391 9602Royal Preston Hospital, Preston, UK
| | - Phillip Godfrey
- grid.411812.f0000 0004 0400 2812James Cook University Hospital, Middlesbrough, UK
| | - Rachel Hawes
- Newcastle Upon Tyne NHS Foundation Trust, Newcastle, UK ,Great North Air Ambulance, Stockton-on-Tees, UK
| | | | | | - Simon Stanworth
- grid.436365.10000 0000 8685 6563NHS Blood and Transplant, Cambridge, UK ,grid.4991.50000 0004 1936 8948Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Julian Thompson
- grid.416201.00000 0004 0417 1173Southmead Hospital, Bristol, UK ,Great West Air Ambulance, Bristol, UK
| | - James Uprichard
- grid.264200.20000 0000 8546 682XSt George’s University Hospital NHS Foundation Trust, London, UK
| | - Simon Walsh
- grid.426467.50000 0001 2108 8951St Mary’s Hospital, Imperial College NHS Foundation Trust, London, UK ,Essex and Hertfordshire Air Ambulance Trust, Essex, UK
| | - Anne Weaver
- grid.139534.90000 0001 0372 5777Barts Health NHS Trust, London, UK
| | - Laura Green
- grid.4868.20000 0001 2171 1133Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT UK ,grid.139534.90000 0001 0372 5777Barts Health NHS Trust, London, UK ,grid.436365.10000 0000 8685 6563NHS Blood and Transplant, Cambridge, UK
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ter Avest E, Carenzo L, Lendrum RA, Christian MD, Lyon RM, Coniglio C, Rehn M, Lockey DJ, Perkins ZB. Advanced interventions in the pre-hospital resuscitation of patients with non-compressible haemorrhage after penetrating injuries. Crit Care 2022; 26:184. [PMID: 35725641 PMCID: PMC9210796 DOI: 10.1186/s13054-022-04052-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 06/02/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract Early haemorrhage control and minimizing the time to definitive care have long been the cornerstones of therapy for patients exsanguinating from non-compressible haemorrhage (NCH) after penetrating injuries, as only basic treatment could be provided on scene. However, more recently, advanced on-scene treatments such as the transfusion of blood products, resuscitative thoracotomy (RT) and resuscitative endovascular balloon occlusion of the aorta (REBOA) have become available in a small number of pre-hospital critical care teams. Although these advanced techniques are included in the current traumatic cardiac arrest algorithm of the European Resuscitation Council (ERC), published in 2021, clear guidance on the practical application of these techniques in the pre-hospital setting is scarce. This paper provides a scoping review on how these advanced techniques can be incorporated into practice for the resuscitation of patients exsanguinating from NCH after penetrating injuries, based on available literature and the collective experience of several helicopter emergency medical services (HEMS) across Europe who have introduced these advanced resuscitation interventions into routine practice.
Graphical Abstract ![]()
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Initial experiences of prehospital blood product transfusions between 2016 and 2020 in Päijät-Häme hospital district, Finland. Scand J Trauma Resusc Emerg Med 2022; 30:39. [PMID: 35668435 PMCID: PMC9169387 DOI: 10.1186/s13049-022-01027-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 05/25/2022] [Indexed: 11/25/2022] Open
Abstract
Background Treating hemorrhaging patients with prehospital blood product transfusions (PHBT) narrows transfusion delays and potentially benefits the patient. We describe our initial experiences of PHBT in a ground-based emergency medical service (EMS), where the transfusion protocol covers both traumatic and nontraumatic hemorrhaging patients. Methods A descriptive retrospective analysis was performed on the records of all the patients receiving red blood cells, freeze-dried plasma, or both during prehospital care from September 2016 to December 2020. The delays of PHBT and the effects on patients’ vital signs were analyzed and reported as the median and interquartile range (IQR) and analyzed using a Wilcoxon Signed rank test. Results 65 patients received prehospital blood product transfusions (PHBT), 29 (45%) were non-traumatic, and 36 (55%) traumatic. The main two reasons for PHBT were blunt trauma (n = 30, 46%) and gastrointestinal hemorrhage (n = 20, 31%). The median time from the emergency call to the start of PHBT was 54 min (IQR 38), and the transfusion began on a median of 61 min (IQR 42) before arrival at the hospital. The median systolic blood pressure improved from a median 76.5 mmHg (IQR 36.5) before transfusion to a median of 116.60 mmHg (IQR 26.5) (p < 0.001) on arrival to the hospital. No transfusion-related severe adverse events were noted. Conclusions Starting PHBT in ground-based EMS is a feasible and viable option. The PHBT began significantly earlier than it would have started on arrival to the hospital, and it seems to be safe and improve patients’ physiology. Study approval D/2603/07.01.04.05/2019.
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10
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Boecker C, Sitzmann N, Halblaub Miranda JL, Suhr H, Wiedemann P, Bieback K, Rudolph M, Klüter H. Noninferior Red Cell Concentrate Quality after Repeated Air Rescue Mission Transport for Prehospital Transfusion. Transfus Med Hemother 2022; 49:172-179. [PMID: 35813604 PMCID: PMC9209961 DOI: 10.1159/000520650] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 10/29/2021] [Indexed: 12/27/2023] Open
Abstract
BACKGROUND Transfusion of red cell concentrates (RCCs) is an integral therapy after severe hemorrhage or trauma. Prehospital transfusion offers an immediate intervention in emergency cases. Air ambulance-based prehospital transfusion, already used in different countries, is currently established in Germany. Limited information is available for regulatory-compliant transport logistics of RCCs and their quality after repeated air rescue missions. Thus, the aim of this study was (i) to validate regulatory-compliant logistics and (ii) to assess product quality, analyzing biochemical parameters and RBC morphology. STUDY DESIGN AND METHODS Due to regulatory requirements, we adapted a rotation system of 1 day transport, 1 day quarantine storage and 1 day storage over the entire RCC shelf life. RCCs transported on air rescue missions (flight group) were compared against a control group, treated identically except for helicopter transport. RCCs were visually inspected, and their temperature was documented throughout the entire rotation cycles. RCCs at the end of shelf life (end point samples) were assessed for levels of hemoglobin, hematocrit, free hemoglobin, hemolysis, mean corpuscular volume, potassium and pH. In addition, morphological changes were assessed using flow morphometry. RESULTS In total 81 RCCs were assessed in the flight group and 50 in the control group. Within the flight group, 30 RCCs were transfused. RCCs were dispatched on average 11 times (7-13 times). The average flight time was 18.3 h (6.6-28.8 h). The rotation system ensured adherence to regulatory guidelines, especially compliance to storage conditions of +2 to +6°C of intermediate storage. Biochemical and morphological quality parameters did not exhibit any changes upon repeated air rescue missions. A correlation with respect to the flight time was not observed either. DISCUSSION The quality of RCCs after repeated air rescue missions is noninferior to control samples regarding biochemical and morphological parameters. The product quality is within German regulations for up to 42 days of storage. The logistics and maintenance of the thermal conditions are safe and feasible. Thus, a rotation system of RCCs offers a regulatory-compliant option to supply air rescue missions with RCCs to allow life-saving prehospital transfusions at the incident scene.
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Affiliation(s)
- Clemens Boecker
- Department of Biotechnology, Mannheim University of Applied Sciences, Mannheim, Germany
- Institute of Transfusion Medicine and Immunology, German Red Cross Blood Service, Baden-Württemberg − Hessen, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Nicole Sitzmann
- Institute of Transfusion Medicine and Immunology, German Red Cross Blood Service, Baden-Württemberg − Hessen, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | | | - Hajo Suhr
- Department of Information Technology, Mannheim University of Applied Sciences, Mannheim, Germany
| | - Philipp Wiedemann
- Department of Biotechnology, Mannheim University of Applied Sciences, Mannheim, Germany
| | - Karen Bieback
- Institute of Transfusion Medicine and Immunology, German Red Cross Blood Service, Baden-Württemberg − Hessen, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Marcus Rudolph
- Scientific working group, DRF Stiftung Luftrettung gAG, Filderstadt, Germany
| | - Harald Klüter
- Institute of Transfusion Medicine and Immunology, German Red Cross Blood Service, Baden-Württemberg − Hessen, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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11
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Levin D, Zur M, Shinar E, Moshe T, Tsur AM, Nadler R, Yazer MH, Epstein D, Avital G, Gelikas S, Glassberg E, Benov A, Chen J. Low-Titer Group O Whole-Blood Resuscitation in the Prehospital Setting in Israel: Review of the First 2.5 Years' Experience. Transfus Med Hemother 2022; 48:342-349. [PMID: 35082565 DOI: 10.1159/000519623] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 09/08/2021] [Indexed: 12/20/2022] Open
Abstract
Introduction The Israeli Defense Forces Medical Corps (IDF-MC) implemented the use of low-titer group O whole blood (LTOWB) as the first-choice resuscitation fluid in the IDF airborne Combat Search and Rescue Unit (IDF-CSAR) for aerial evacuation of both military and civilian casualties in June 2018 for injured patients with hemorrhagic shock and at least one of the following: systolic blood pressure <90 mm Hg, heart rate >130 beats/min, deterioration of consciousness without head injury or hemoglobin concentration ≤7 g/dL. Method All casualties treated with LTOWB by IDF-CSAR providers from June 2018 to January 2021 were included. Demographic and prehospital treatment data were collected in order to check compliance and adherence to the IDF-MC guidelines. This is a follow-up retrospective report. Results Overall, 1,608 LTOWB units were supplied to the IDF-CSAR during the study period. Of these, 33 were transfused to 27 casualties; 17 (69%) with blunt injury, 8 (29.6%) with penetrating injuries, and 1 (3.7%) with gastrointestinal bleeding without trauma. The leading cause of injury was motor vehicle accidents. A total of 23 casualties received 1 unit of LTOWB, 3 received 2 units and 1 patient received 4 units. Two casualties were children. The median heart rate was 120 beats/min, 8 (29.6%) casualties had heart rates >130 beats/min. Median systolic blood pressure was 95 mm Hg, 7 (26%) casualties had blood pressure <90 mm Hg. The median Glasgow Coma Score was 14. No adverse reactions were documented following the administration of LTOWB. 77.8% of patients received LTOWB in adherence to the guidelines. Conclusion Appropriate administration of LTOWB has improved over time in IDF-CSAR. Using LTOWB is feasible and simpler than administering packed red blood cells and plasma concurrently. Further efforts are needed to introduce LTOWB in other prehospital and in-hospital scenarios, with an increase in the maximum antibody titer threshold, to meet the expected increase in demand.
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Affiliation(s)
- Dan Levin
- Trauma and Combat Medicine Branch, Israel Defense Forces Medical Corps, Tel Hashomer, Ramat Gan, Israel
| | - Maoz Zur
- Military Medical Academy, Medical Corps, Israel Defense Forces, Shefayim, Israel
| | - Eilat Shinar
- Magen David National Blood Services, Ramat Gan, Israel.,Faculty of Health Sciences, Ben Gurion University of the Negev, Be'er Scheva, Israel
| | - Tzadok Moshe
- Magen David National Blood Services, Ramat Gan, Israel.,Faculty of Health Sciences, Ben Gurion University of the Negev, Be'er Scheva, Israel
| | - Avishai M Tsur
- Trauma and Combat Medicine Branch, Israel Defense Forces Medical Corps, Tel Hashomer, Ramat Gan, Israel.,Department of Medicine B, Sheba Medical Center, Tel Hashomer, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Ramat Gan, Israel
| | - Roy Nadler
- Trauma and Combat Medicine Branch, Israel Defense Forces Medical Corps, Tel Hashomer, Ramat Gan, Israel.,Department of General Surgery and Transplantation - Surgery B, Chaim Sheba Medical Center, Tel Hashomer, affiliated with the Sackler School of Medicine, Ramat Gan, Israel
| | - Mark H Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Pathology, Tel Aviv University, Tel Aviv, Israel
| | - Danny Epstein
- Trauma and Combat Medicine Branch, Israel Defense Forces Medical Corps, Tel Hashomer, Ramat Gan, Israel.,Critical Care Division, Rambam Health Care Campus, Haifa, Israel
| | - Guy Avital
- Trauma and Combat Medicine Branch, Israel Defense Forces Medical Corps, Tel Hashomer, Ramat Gan, Israel.,Division of Anesthesia, Intensive Care and Pain Management, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Shaul Gelikas
- Trauma and Combat Medicine Branch, Israel Defense Forces Medical Corps, Tel Hashomer, Ramat Gan, Israel
| | - Elon Glassberg
- Trauma and Combat Medicine Branch, Israel Defense Forces Medical Corps, Tel Hashomer, Ramat Gan, Israel.,The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel.,The Uniformed Services, University of the Health Sciences, Bethesda, Maryland, USA
| | - Avi Benov
- Trauma and Combat Medicine Branch, Israel Defense Forces Medical Corps, Tel Hashomer, Ramat Gan, Israel.,The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Jacob Chen
- Trauma and Combat Medicine Branch, Israel Defense Forces Medical Corps, Tel Hashomer, Ramat Gan, Israel.,Meir Medical Center, affiliated with Sackler School of Medicine, Tel Aviv University, Kfar Saba, Israel
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12
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Tucker H, Avery P, Brohi K, Davenport R, Griggs J, Weaver A, Green L. Outcome measures used in clinical research evaluating prehospital blood component transfusion in traumatically injured bleeding patients: A systematic review. J Trauma Acute Care Surg 2021; 91:1018-1024. [PMID: 34254958 DOI: 10.1097/ta.0000000000003360] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Trial outcomes should be relevant to all stakeholders and allow assessment of interventions' efficacy and safety at appropriate timeframes. There is no consensus regarding outcome measures in the growing field of prehospital trauma transfusion research. Harmonization of future clinical outcome reporting is key to facilitate interstudy comparisons and generate cohesive, robust evidence to guide practice. The objective of this study was to evaluate outcome measures reported in prehospital trauma transfusion trials. METHODS Data Sources, Eligibility Criteria, Participants, and InterventionsWe conducted a scoping systematic review to identify the type, number, and definitions of outcomes reported in randomized controlled trials, and prospective and retrospective observational cohort studies investigating prehospital blood component transfusion in adult and pediatric patients with traumatic hemorrhage. Electronic database searching of PubMed, Embase, Web of Science, Cochrane, OVID, clinical trials.gov, and the Transfusion Evidence Library was completed in accordance with Preferred Reporting Items for Meta-analyses guidelines.Study Appraisal and Synthesis MethodsTwo review authors independently extracted outcome data. Unique lists of salutogenic (patient-reported health and wellbeing outcomes) and nonsalutogenic focused outcomes were established. RESULTS A total of 3,471 records were identified. Thirty-four studies fulfilled the inclusion criteria: 4 military (n = 1,566 patients) and 30 civilian (n = 14,398 patients), all between 2000 and 2020. Two hundred twelve individual non-patient-reported outcomes were identified, which collapsed into 20 outcome domains with varied definitions and timings. All primary outcomes measured effectiveness, rather than safety or complications. Sixty-nine percent reported mortality, with 11 different definitions. No salutogenic outcomes were reported. CONCLUSION There is heterogeneity in outcome reporting and definitions, an absence of patient-reported outcome, and an emphasis on clinical effectiveness rather than safety or adverse events in prehospital trauma transfusion trials. We recommend stakeholder consultation and a Delphi process to develop a clearly defined minimum core outcome set for prehospital trauma transfusion trials. LEVEL OF EVIDENCE Scoping systematic review, level III.
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Affiliation(s)
- Harriet Tucker
- From the Centre for Trauma Sciences, Blizard Institute (H.T., K.B., R.D., L.G.), Queen Mary University of London, London, United Kingdom; Southmead Hospital (P.A.), North Bristol NHS Trust, Bristol, United Kingdom; Learning and Development (P.A.), South Western Ambulance Service NHS Foundation Trust, Bristol, United Kingdom; Air Ambulance Kent Surrey Sussex (J.G., H.T.), Rochester, United Kingdom; Faculty of Health Sciences (J.G.), University of Surrey, Guildford, United Kingdom; London's Air Ambulance (A.W.), London, United Kingdom; Barts Health NHS Foundation Trust (K.B., R.D., A.W., L.G.), London, United Kingdom; and NHS Blood and Transplant (L.G.), London, United Kingdom
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13
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Abstract
PURPOSE OF REVIEW Posttraumatic bleeding following major trauma is life threatening for the patient and remains a major global health issue. Bleeding after major trauma is worsened by trauma-induced coagulopathy (TIC). TIC consists of acute trauma coagulopathy and resuscitation coagulopathy. The early diagnosis and management of prehospital TIC management are challenging. RECENT FINDINGS Concepts for early diagnosis and management of civilian prehospital TIC management are evolving. The feasibility of prehospital blood component as well as coagulation factor transfusion has been proven. SUMMARY Due to different national guidelines and regulations of blood component therapies there is a wide heterogeneity in concepts of prehospital damage control resuscitation. Tranexamic acid administration is widely accepted, whereas the transfusion of whole blood, blood components, or coagulations factors needs further examination in the civilian setting.
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14
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Prehospital Transfusion of Red Blood Cells and Plasma by an Urban Ground-Based Critical Care Team. Prehosp Disaster Med 2020; 36:170-174. [PMID: 33349291 DOI: 10.1017/s1049023x20001491] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION 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. METHODS 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. RESULTS 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. CONCLUSION 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.
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15
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Convertino VA, Schauer SG, Weitzel EK, Cardin S, Stackle ME, Talley MJ, Sawka MN, Inan OT. Wearable Sensors Incorporating Compensatory Reserve Measurement for Advancing Physiological Monitoring in Critically Injured Trauma Patients. SENSORS (BASEL, SWITZERLAND) 2020; 20:E6413. [PMID: 33182638 PMCID: PMC7697670 DOI: 10.3390/s20226413] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 11/02/2020] [Accepted: 11/04/2020] [Indexed: 12/21/2022]
Abstract
Vital signs historically served as the primary method to triage patients and resources for trauma and emergency care, but have failed to provide clinically-meaningful predictive information about patient clinical status. In this review, a framework is presented that focuses on potential wearable sensor technologies that can harness necessary electronic physiological signal integration with a current state-of-the-art predictive machine-learning algorithm that provides early clinical assessment of hypovolemia status to impact patient outcome. The ability to study the physiology of hemorrhage using a human model of progressive central hypovolemia led to the development of a novel machine-learning algorithm known as the compensatory reserve measurement (CRM). Greater sensitivity, specificity, and diagnostic accuracy to detect hemorrhage and onset of decompensated shock has been demonstrated by the CRM when compared to all standard vital signs and hemodynamic variables. The development of CRM revealed that continuous measurements of changes in arterial waveform features represented the most integrated signal of physiological compensation for conditions of reduced systemic oxygen delivery. In this review, detailed analysis of sensor technologies that include photoplethysmography, tonometry, ultrasound-based blood pressure, and cardiogenic vibration are identified as potential candidates for harnessing arterial waveform analog features required for real-time calculation of CRM. The integration of wearable sensors with the CRM algorithm provides a potentially powerful medical monitoring advancement to save civilian and military lives in emergency medical settings.
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Affiliation(s)
- Victor A. Convertino
- Battlefield Health & Trauma Center for Human Integrative Physiology, US Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, TX 78234, USA;
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA;
| | - Steven G. Schauer
- Battlefield Health & Trauma Center for Human Integrative Physiology, US Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, TX 78234, USA;
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA;
- Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, TX 78234, USA
| | - Erik K. Weitzel
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA;
- Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, TX 78234, USA
- 59th Medical Wing, JBSA Lackland, San Antonio, TX 78236, USA
| | - Sylvain Cardin
- Navy Medical Research Unit, JBSA Fort Sam Houston, San Antonio, TX 78234, USA;
| | - Mark E. Stackle
- Commander, US Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, TX 78234, USA;
| | - Michael J. Talley
- Commanding General, US Army Medical Research and Development Command, Fort Detrick, Frederick, MD 21702, USA;
| | - Michael N. Sawka
- Georgia Institute of Technology, Atlanta, GA 30332, USA; (M.N.S.); (O.T.I.)
| | - Omer T. Inan
- Georgia Institute of Technology, Atlanta, GA 30332, USA; (M.N.S.); (O.T.I.)
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16
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Nadler R, Tsur AM, Yazer MH, Shinar E, Moshe T, Benov A, Glassberg E, Epstein D, Chen J. Early experience with transfusing low titer group O whole blood in the pre-hospital setting in Israel. Transfusion 2020; 60 Suppl 3:S10-S16. [PMID: 32478889 DOI: 10.1111/trf.15602] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 10/23/2019] [Accepted: 11/01/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND The Israeli Defense Force Medical Corps (IDF-MC) recently implemented the use of low titer group O whole blood (LTOWB) in the airborne combat search and rescue unit (CSAR) for both military and civilian patients during transport to definitive care. LTOWB is preferentially used by the CSAR instead of red blood cell units and freeze-dried plasma (FDP) for patients with signs of hemorrhagic shock. Ten percent of group O donors were eligible to donate LTOWB as they had anti-A and -B IgM titers of <50. METHODS All patients treated by CSAR providers with LTOWB between July 2018 and June 2019 were included. RESULTS Between July 2018 and June 2019, eight patients have received 10 units of LTOWB. All patients suffered blunt injuries, 6 out of 8 (75%) of whom were due to motor vehicle accidents. Four patients (4 out of 8, 50%) received a single LTOWB unit, two patients (2 out of 8, 25%) received two units. Two pediatric patients received fewer than one unit of LTOWB. Median (range) heart rate was 130 (30-150) bpm, median systolic blood pressure was 107 (80-124) mmHg, and median Glasgow coma scale was 8 (on a scale of 3-15). For four (4 out of 8, 50%) patients, LTOWB was the only blood product used for volume resuscitation. All six adult patients were treated with 1 g of tranexamic acid at the point of injury. CONCLUSIONS The CSAR has successfully implemented a LTOWB program for the pre-hospital treatment of bleeding patients, and as its experience grows this product will be made available to other units and in civilian hospitals.
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Affiliation(s)
- Roy Nadler
- Surgeon General's HQ, Israel Defense Force, Ramat Gan, Israel.,Department of Surgery and Transplantation B, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Avishai M Tsur
- Surgeon General's HQ, Israel Defense Force, Ramat Gan, Israel
| | - Mark H Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Pathology, Tel Aviv University, Tel Aviv, Israel
| | - Eilat Shinar
- National Blood Services, Magen David Adom, Ramat Gan, Israel
| | - Tzadok Moshe
- National Blood Services, Magen David Adom, Ramat Gan, Israel
| | - Avi Benov
- Surgeon General's HQ, Israel Defense Force, Ramat Gan, Israel.,Bar-Ilan University Faculty of Medicine (G.E.), Safed, Israel
| | - Elon Glassberg
- Surgeon General's HQ, Israel Defense Force, Ramat Gan, Israel.,Bar-Ilan University Faculty of Medicine (G.E.), Safed, Israel.,Department of Surgery, the Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Danny Epstein
- Surgeon General's HQ, Israel Defense Force, Ramat Gan, Israel
| | - Jacob Chen
- Surgeon General's HQ, Israel Defense Force, Ramat Gan, Israel
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17
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Choi HJ, Kim HI. Introduction and characteristics of helicopter emergency medical services. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2020. [DOI: 10.5124/jkma.2020.63.4.188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Helicopter emergency medical services (HEMS) are a part of air medical services. The transportation of patients using helicopters or airplanes is a core element of the air medical services. HEMS have developed from militarybased transportation, which used helicopters on the battlefield. HEMS have played an important role in properly transporting critical patients before the golden time elapses. The optimal strategies for the operation of HEMS at any emergency medical system are dependent on the characteristics of the regional emergency medical system, diversitiy of HEMS organizations, and the legal background of each country. Therefore, every participant, including the government, medical personnel, and HEMS organizations, should concentrate their efforts toward the establishment of HEMS. Other than the factors related to patients, the key element in facilitating the establishment of HEMS is the safety of the flight and crew members.
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18
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van Turenhout EC, Bossers SM, Loer SA, Giannakopoulos GF, Schwarte LA, Schober P. Pre-hospital transfusion of red blood cells. Part 1: A scoping review of current practice and transfusion triggers. Transfus Med 2020; 30:86-105. [PMID: 32080942 PMCID: PMC7317877 DOI: 10.1111/tme.12667] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 12/18/2019] [Accepted: 01/16/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVES The primary aim of this scoping review is to describe the current use of pre-hospital transfusion of red blood cells (PHTRBC) and to evaluate criteria used to initiate PHTRBC. The effects on patients' outcomes will be reviewed in Part 2. BACKGROUND Haemorrhage is a preventable cause of death in trauma patients, and transfusion of red blood cells is increasingly used by Emergency Medical Services (EMS) for damage control resuscitation. However, there are no guidelines and little consensus on when to initiate PHTRBC. METHODS PubMed and Web of Science were searched through January 2019; 71 articles were included. RESULTS Transfusion triggers vary widely and involve vital signs, clinical signs of poor tissue perfusion, point of care measurements and pre-hospital ultrasound imaging. In particular, hypotension (most often defined as systolic blood pressure ≤ 90 mmHg), tachycardia (most often defined as heart rate ≥ 120/min), clinical signs of poor perfusion (eg, prolonged capillary refill time or changes in mental status) and injury type (ie, penetrating wounds) are common pre-hospital transfusion triggers. CONCLUSIONS PHTRBC is increasingly used by Emergency Medical Services, but guidelines on when to initiate transfusion are lacking. We identified the most commonly used transfusion criteria, and these findings may provide the basis for consensus-based pre-hospital transfusion protocols.
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Affiliation(s)
| | - Sebastiaan M. Bossers
- Department of AnaesthesiologyAmsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Stephan A. Loer
- Department of AnaesthesiologyAmsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Georgios F. Giannakopoulos
- Department of Trauma SurgeryAmsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
- Helicopter Emergency Medical Service “Lifeliner 1”Amsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Lothar A. Schwarte
- Department of AnaesthesiologyAmsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
- Helicopter Emergency Medical Service “Lifeliner 1”Amsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Patrick Schober
- Department of AnaesthesiologyAmsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
- Helicopter Emergency Medical Service “Lifeliner 1”Amsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
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19
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van Turenhout EC, Bossers SM, Loer SA, Giannakopoulos GF, Schwarte LA, Schober P. Pre-hospital transfusion of red blood cells. Part 2: A systematic review of treatment effects on outcomes. Transfus Med 2020; 30:106-133. [PMID: 31903684 PMCID: PMC7317762 DOI: 10.1111/tme.12659] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 12/06/2019] [Indexed: 12/11/2022]
Abstract
The primary aim of this systematic review is to describe the effects of prehospital transfusion of red blood cells (PHTRBC) on patient outcomes. Damage control resuscitation attempts to prevent death through haemorrhage in trauma patients. In this context, transfusion of red blood cells is increasingly used by emergency medical services (EMS). However, evidence on the effects on outcomes is scarce. PubMed and Web of Science were searched through January 2019; 55 articles were included. No randomised controlled studies were identified. While several observational studies suggest an increased survival after PHTRBC, consistent evidence for beneficial effects of PHTRBC on survival was not found. PHTRBC appears to improve haemodynamic parameters, but there is no evidence that shock on arrival to hospital is averted, nor of an association with trauma induced coagulopathy or with length of stay in hospitals or intensive care units. In conclusion, PHTRBC is increasingly used by EMS, but there is no strong evidence for effects of PHTRBC on mortality. Further research with study designs that allow causal inferences is required for more conclusive evidence. The combination of PHTRBC with plasma, as well as the use of individualised transfusion criteria, may potentially show more benefits and should be thoroughly investigated in the future. The review was registered at Prospero (CRD42018084658).
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Affiliation(s)
| | - Sebastiaan M. Bossers
- Department of Anaesthesiology, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Stephan A. Loer
- Department of Anaesthesiology, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Georgios F. Giannakopoulos
- Department of Trauma Surgery, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
- Helicopter Emergency Medical Service “Lifeliner 1”, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Lothar A. Schwarte
- Department of Anaesthesiology, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
- Helicopter Emergency Medical Service “Lifeliner 1”, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Patrick Schober
- Department of Anaesthesiology, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
- Helicopter Emergency Medical Service “Lifeliner 1”, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
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20
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Shander A, Zacharowski K, Spahn DR. Red cell use in trauma. Curr Opin Anaesthesiol 2020; 33:220-226. [PMID: 32004168 DOI: 10.1097/aco.0000000000000837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Red cell transfusions are commonly used in management of hemorrhage in trauma patients. The appropriate indications and criteria for transfusion are still debated. Here, we summarize the recent findings on the use of red cell transfusion in trauma setting. RECENT FINDINGS Recent evidence continues to support the long-established link between allogeneic transfusion and worse clinical outcomes, reinstating the importance of more judicious use of allogeneic blood and careful consideration of benefits versus risks when making transfusion decisions. Studies support restrictive transfusion strategies (often based on hemoglobin thresholds of 7-8 g/dl) in most patient populations, although some argue more caution in specific populations (e.g. patients with traumatic brain injury) and more studies are needed to determine if these patients benefit from less restrictive transfusion strategies. It should be remembered that anemia remains an independent risk factor for worse outcomes and red cell transfusion does not constitute a lasting treatment. Anemia should be properly assessed and managed based on the cause and using hematinic medications as indicated. SUMMARY Although the debate on hemoglobin thresholds for transfusion continues, clinicians should not overlook proper management of the underlying issue (anemia).
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Affiliation(s)
- Aryeh Shander
- Department of Anesthesiology and Critical Care Medicine; Englewood Hospital and Medical Center.,TeamHealth Research Institute; Englewood.,Icahn School Of Medicine at Mount Sinai, New York, NY, USA
| | - Kai Zacharowski
- Department of Anesthesiology, Intensive Care Medicine & Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt, Main, Germany
| | - Donat R Spahn
- Institute of Anesthesiology, University and University Hospital Zürich, Zürich, Switzerland
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Abstract
Trauma is a leading cause of death worldwide in persons under 44 years of age, and uncontrolled haemorrhage is the most common preventable cause of death in this patient group. The transfusion management of trauma haemorrhage is unrecognisable from 20 years ago. Changes in clinical practice have been driven primarily by an increased understanding of the pathophysiology of trauma-induced coagulopathy (TIC), which is associated with poor clinical outcomes, including a 3- to 4-fold increased risk of death. Targeting this coagulopathy alongside changes to surgical and anaesthetic practices (an overarching strategy known as damage control surgery/damage control resuscitation) has led to a significant reduction in mortality rates over the last two decades. This narrative review will discuss the transfusion practices that are currently used for trauma haemorrhage and the evidence that supports these practices.
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Affiliation(s)
- Nicola S Curry
- Oxford Haemophilia & Thrombosis Centre, Department of Haematology, Oxford University Hospitals NHS Trust, Churchill Hospital, Oxford, UK.,NIHR BRC, Blood Theme, Oxford Centre for Haematology, Oxford, UK
| | - Ross Davenport
- Centre for Trauma Sciences, Blizard Institute, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, UK
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