Epidemiological and Accounting Analysis of Ground Ambulance Whole Blood Transfusion

Low-titer group O whole blood in military ground ambulances: Lessons from the Israel Defense Forces initial experience

BACKGROUND

Cold-stored low-titer group O whole blood (LTOWB) has become increasingly utilised in both prehospital and in-hospital settings for resuscitation of traumatic haemorrhage. However, implementing the use of LTOWB to ground medical teams has been limited due to logistic challenges.

METHODS

In 2022, the Israel Defense Forces (IDF) started using LTOWB in ambulances for the first time in Israel. This report details the initial experience of this rollout and presents a case-series of the first patients treated with LTOWB.

RESULTS

Between January-December 2022, seven trauma patients received LTOWB administered by ground IDF intensive care ambulances after presenting with profound shock. Median time from injury to administration of LTOWB was 35 min. All patients had evidence of severe bleeding upon hospital arrival with six undergoing damage control laparotomy and all but one surviving to discharge.

CONCLUSIONS

The implementation of LTOWB in ground medical units is in its early stages, but continued experience may demonstrate its feasibility, safety, and effectiveness in the prehospital setting. Further research is necessary to fully understand the indications, methodology, and benefits of LTOWB in resuscitating severely injured trauma patients in this setting.

Current summary of the evidence in drone-based emergency medical services care

Interventions for many medical emergencies including cardiac arrests, strokes, drug overdoses, seizures, and trauma, are critically time-dependent, with faster intervention leading to improved patient outcomes. Consequently, a major focus of emergency medical services (EMS) systems and prehospital medicine has been improving the time until medical intervention in these time-sensitive emergencies, often by reducing the time required to deliver critical medical supplies to the scene of the emergency. Medical indications for using unmanned aerial vehicles, or drones, are rapidly expanding, including the delivery of time-sensitive medical supplies. To date, the drone-based delivery of a variety of time-critical medical supplies has been evaluated, generating promising data suggesting that drones can improve the time interval to intervention through the rapid delivery of automatic external defibrillators (AEDs), naloxone, antiepileptics, and blood products. Furthermore, the improvement in the time until intervention offered by drones in out-of-hospital emergencies is likely to improve patient outcomes in time-dependent medical emergencies. However, barriers and knowledge gaps remain that must be addressed. Further research demonstrating functionality in real-world scenarios, as well as research that integrates drones into the existing EMS structure will be necessary before drones can reach their full potential. The primary aim of this review is to summarize the current evidence in drone-based Emergency Medical Services Care to help identify future research directions.

Continuum of care: a multiagency approach to seamless warmed prehospital whole blood resuscitation of a patient with noncompressible truncal hemorrhage

BackgroundPrehospital transfusion capabilities vary widely in the United States. Here we describe a case of prehospital resuscitation using warmed, whole blood in a patient with penetrating torso trauma and associated hemorrhagic shock.Case ReportA 68-year-old man sustained a single gunshot wound to the left chest and was found to have a shock index of 1.5 at the time of emergency medical services (EMS) arrival. Rapid peripheral intravenous and central venous access enabled the infusion of warmed low-titer O-positive whole blood. The EMS crew intentionally resuscitated the patient before managing the airway by means of rapid sequence intubation. An air medical services helicopter crew assumed patient care from the ground EMS crew and continued the warmed, whole blood transfusion during the flight to a regional Level 1 trauma center. The patient went directly to the operating room from the helipad, underwent definitive operative management, and was ultimately discharged home on hospital day nine.ConclusionEarly recognition of hemorrhagic shock, implementation of prehospital transfusion protocols that emphasize transfusion of warmed blood without interruption, and an organized, regional approach to trauma care are critical for improving patient survival.

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

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

Coagulation function of never frozen liquid plasma stored for 40 days

BACKGROUND

Never frozen liquid plasma (LP) has limited shelf life versus fresh frozen plasma (FFP) or plasma frozen within 24 h (PF24). Previous studies showed decreasing factor activities after Day (D)14 in thawed FFP but no differences between LP and FFP until D10. This study examined LP function through D40.

STUDY DESIGN AND METHODS

FFP and PF24 were stored at -20°C until assaying. LP was assayed on D5 then stored (4°C) for testing through D40. A clinical coagulation analyzer measured Factor (F)V, FVIII, fibrinogen, prothrombin time (PT), and activated partial thromboplastin time (aPTT). Thromboelastography (TEG) and thrombogram measured functional coagulation. Ristocetin cofactor assay quantified von Willebrand factor (vWF) activity. Residual platelets were counted.

RESULTS

FV/FVIII showed diminished activity over time in LP, while PT and aPTT both increased over time. LP vWF declined significantly by D7. Fibrinogen remained high through D40. Thrombin lagtime was delayed in LP but consistent to D40, while peak thrombin was significantly lower in LP but did not significantly decline over time. TEG R-time and angle remained constant. LP and PF24 (with residual platelets) had initially higher TEG maximum amplitudes (MA), but by D14 LP was similar to FFP.

CONCLUSION

Despite significant declines in some factors in D40 LP, fibrinogen concentration and TEG MA were stable suggesting stored LP provides fibrinogen similarly to frozen plasmas even at D40. LP is easier to store and prepare for prehospital transfusion, important benefits when the alternative is crystalloid.

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

BACKGROUND

Hemorrhage is the leading cause of death in trauma patients with most fatalities occurring before reaching a higher level of care-this applies to both the civilian setting and the military combat setting. Hemostatic resuscitation with increased emphasis on blood transfusion while limiting use of crystalloids has become routine in trauma care. However, the prehospital setting-especially in combat-presents unique challenges with regard to storage, transport, and administration. We sought to evaluate available technology on the market for storage and administration technology that is relevant to the prehospital setting.

STUDY DESIGN AND METHODS

We conducted a market review of available technology through subject-matter expert inquiry, reviews of published literature, reviews of Federal Drug Administration databases, internal military publications, and searches of Google.

RESULTS

We reviewed and described a total of 103 blood transporters, 22 infusers, and 6 warmers.

CONCLUSIONS

The risk of on-scene fatality in trauma patients and recent developments in trauma care demonstrate the need for prehospital transfusion. These transfusions have been logistically prohibited in many operations. We have reviewed the current commercially available equipment and recommended pursuit of equipment that improves accessibility to field transfusion. Current technology has limited applicability for the prehospital setting and is further limited for the military setting.

Prehospital resuscitation

Traumatic injury is the leading cause of death in young people in the USA. Our knowledge of prehospital resuscitation is constantly evolving and is often informed by research based on military experience. A move toward balanced blood product resuscitation and away from excessive crystalloid use has led to improvements in outcomes for trauma patients. This has been facilitated by new technologies allowing more front-line use of blood products as well as use of tranexamic acid in the prehospital setting. In this article, we review current practices in prehospital resuscitation and the studies that have informed these practices.

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

INTRODUCTION

The implementation of a low-titer O+ whole blood (LTOWB) resuscitation algorithm, particularly in the prehospital environment, has several inherent challenges, including cost, limited and inconsistent supply, and the logistics of cold-chain management. The Southwest Texas Regional Advisory Council has implemented the nation's first multidisciplinary, multi-institutional regional LTOWB program. This research effort was to illustrate the successful deployment of LTOWB within a regional trauma system.

MATERIALS AND METHODS

A deliberate systems approach to the deployment of LTOWB was used. Tenets of this program included the active management of blood donor sources and blood supply levels to minimize wastage as a result of expiration, maximize product utilization, the use of prehospital transfusion triggers, and efforts to decrease program costs prehospital agencies. A novel LTOWB rotation system was established using the concept of a "rotation site" and "rotation center." Standardized transfusion criteria, a regional approved equipment list, a regional Prehospital Blood Product Transfusion Record, and a robust multilevel communication plan serves as the framework for the program. The San Antonio Whole Blood Consortium was developed to create a consensus driven forum to manage and guide the program.

RESULTS

From January 2018 to October 2019, LTOWB has been placed at 18 helicopter emergency medical services (HEMS) bases, 12 ground emergency medical service (EMS) agencies, 1 level I trauma center, and 1 level IV trauma center. A total of 450 patients have received a prehospital LTOWB transfusion. Program wide, the wastage rate of LTOWB due to expiration is between 1% and 2%. No complications related to prehospital LTOWB administration have been identified.

DISCUSSION

This work demonstrates a novel model for the development of a trauma system LTOWB program. The program's implementation augments remote damage control resuscitation strategies and requires the integration and collaboration of a multidisciplinary stakeholder team to optimize efficiency, performance, and safety of the program.

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

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

Low titer group O whole blood resuscitation: Military experience from the point of injury

INTRODUCTION

In the far forward combat environment, the use of whole blood is recommended for the treatment of hemorrhagic shock after injury. In 2016, US military special operations teams began receiving low titer group O whole blood (LTOWB) for use at the point of injury (POI). This is a case series of the initial 15 patients who received LTOWB on the battlefield.

METHODS

Patients were identified in the Department of Defense Trauma Registry, and charts were abstracted for age, sex, nationality, mechanism of injury, injuries and physiologic criteria that triggered the transfusion, treatments at the POI, blood products received at the POI and the damage-control procedures done by the first surgical team, next level of care, initial interventions by the second surgical team, Injury Severity Score, and 30-day survival. Descriptive statistics were used to characterize the clinical data when appropriate.

RESULTS

Of the 15 casualties, the mean age was 28, 50% were US military, and 63% were gunshot wounds. Thirteen patients survived to discharge, one died of wounds after arrival at the initial resuscitative surgical care, and two died prehospital. The mean Injury Severity Score was 21.31 (SD, 18.93). Eleven (68%) of the causalities received additional blood products during evacuation/role 2 and/or role 3. Vital signs were available for 10 patients from the prehospital setting and 9 patients upon arrival at the first surgical capable facility. The mean systolic blood pressure was 80.5 prehospital and 117 mm Hg (p = 0.0002) at the first surgical facility. The mean heart rate was 105 beats per minute prehospital and 87.4 beats per minute (p = 0.075) at the first surgical facility. The mean hospital stay was 24 days.

CONCLUSION

The use of cold-stored LTOWB at POI is feasible during combat operations. Further data are needed to validate and inform best practice for POI transfusion.

LEVEL OF EVIDENCE

Therapeutic study, level V.