Prehospital blood transfusion: Rationale and experience of Greater Sydney Area HEMS

Dr Peter B Sherren, Dr Brian J Burns

Department of Prehospital Emergency medicine, Greater Sydney Area HEMS

Background

• Uncontrolled haemorrhage is the commonest cause of preventable trauma deaths. Holcomb et al Ann Surg 2008.

• Damage control resuscitation (DCR) improves outcomes and mortality. Cotton BA et al Ann Surg 2011

• DCR should start at the time of injury not in the ED

Case - Paul

MIST• M ~40 yr old male involved in high speed MBC

• I Complete traumatic Rt forequarter amputation+++ blood, ?pelvis, CHI

• S Agonal breaths, SpO2 not recording, HR 160, weak/thready carotid pulse only, GCS 7→3/15, Pupils 4/4 sluggish.

• T O2 NRB, 1XIV, 500ml crystalloid

HEMS management• 2xIO - IV tissued• Sux only RSI - ETCO2 quantatively low but present.• Rt thoracostomy• Direct compression wound• Sam Sling• 1g TXA• 500ml crystalloid & 250ml HTS• Persistent volume issues• Depart scene (scene time 23 mins)• Massive transfusion pre-alert, 2xPRBC given on

helipad arrival

On arrival in the ED• AB ok• C

• Unstable but volume responsive with haemostatic resuscitation

• pH 6.7, BE -26, Lact 16• Hb 10.6, HCT 0.28, INR

2.6 APTTR 2.1

• Taken to theatres for surgical haemostasis

• Debrief points? Good level of care?

Coagulopathy in trauma

• Medical• Bleeding diathesis• Anticoagulants

• Trauma induced coagulopathy

• Acute traumatic coagulopathy (↑TM/APC → ↓V/VIII and ↑fibrinolysis)

• Hypothermia• Acidaemia• Dilutional

Why not use blood prehospital?

• Expense• Short shelf half-life• Difficult storage• Wastage• Tracking transfused patients• Generic concerns re. blood transfusions

Greater Sydney Area HEMS• Three HEMS bases• Four operational rotary

wings • ALL bases carry PRBCs• 3-4 units depending on

base• Sealed ‘Golden hour’

box• Stable for 72 hrs• Replaced and tracked by

local hospital

SOP and good clinical governance

Methods

• All PREHOSPITAL missions involving a blood transfusion

• From June 2007-December 2012

• Prospectively completed electronic database was utilised to identify patients and extract data

Results• 158 missions were identified, of which 147

patient’s data sets were complete• 69.3% male with median (IQR) age of 34.5 (22-

52)• 382 units of PRBCs were transfused to 147

trauma patients (median 3u, range 1-6u)• Acceptable wastage (66u)• No documented transfusion reactions

Demographic data, timings and Coded Revised Trauma Score (RTSc2). n=147

 Mechanism of injury (%)

  

  Motor vehicle collision Motor bike collision Pedestrian versus car Gunshot wound/stabbing Fall from a height Recreational Other

 87 (59.1)20 (13.6)

9 (6.1)9 (6.1)5 (3.4)6 (4.1)

11 (7.5) Number of patients trapped on arrival (%)

 45 (30.6)

 Scene time in minutes, mean (SD)

 49.9 (27.8)

 Time from tasking to arrival at hospital in minutes, mean (SD)

 126.5 (51.3)

 Heart rate, median (IQR)

 115 (90-130)

 Systolic blood pressure in mmHg, median (IQR)

 80 (65-105)

 RTSc

2, median (IQR) 

5.967 (4.083-6.904) Volume of crystalloid given in ml, median (IQR)

 500 (0-1500)

 Pronounced life extinct on scene

 22 (15.0)

Intervention  Total (n=147)

 Rapid sequence intubation

 96 (65.3)

 Cold endotracheal intubation

 15 (10.2)

 Surgical airway

 1 (0.7)

 Thoracostomy (Open or tube)

 59 (40.1)

 Thoracotomy

 3 (2.0)

 Pelvic binder or fracture splintage

 89 (60.5)

 Intraosseous insertion

 22 (15.0)

Humerus Tibia Femur

 19101

 Tourniquet application

 15 (10.2)

 Positive E-FAST

 18/27

o Abdominal free fluido Pneumothorax o Haemothorax

 1541

Conclusion• Prehospital blood carriage is logistically

feasible with minimal wastage• Prehospital blood transfusion is safe• The distances and mission times involved

in our service makes prehospital blood transfusion vital

• Coagulation product carriage for massive transfusion is the next step

Questions?