About 20 years ago, it was 10 p.m. on a busy Friday when our unit was assigned to a shooting at a nearby gas station. Dispatch stated police were already on the scene calling for a rush. When we arrived five minutes later, an officer told us that a witness saw a teenaged male come in and point a handgun at the 22-year-old male clerk and insist on all the cash in the register. There were words and suddenly the gun went off and the assailant grabbed some cash and ran out the front door. The police stated this had happened 10 minutes earlier. The clock was ticking.
We found the clerk sitting on the floor holding his abdomen. There was very little external bleeding, but based on his rapid, weak, and thready radial pulse; his pale, clammy skin; and his fear of impending doom, he most likely had significant internal bleeding.
We quickly examined him for any exit wounds, listened for and found bilateral lung sounds, got some high concentration oxygen applied, and placed him on the stretcher in a supine position. The medic prepared an IV set and started a large-bore IV line to run in a liter of normal saline as the ambulance was traveling lights and siren en route to the ED.
That was 8 minutes on the scene, and the ride to the trauma center took another 10 minutes. We were fortunate to have a trauma center close by. En route, the patient’s level of consciousness went from alert to unresponsive as the crew pushed in a second liter, ventilated with a BVM, and began chest compressions. Most importantly, we called ahead, and on arrival in the ED a team was ready to continue the care. A very short time after arrival he was taken to surgery. Time was running out.
Later that night we found out that he had died.
Once a week at the trauma center, cases were reviewed and the meetings wer open to the crews who were on the call as well as the ED staff and surgical team. We made sure to attend the case review. In this case a young, healthy male died because he was in the wrong place at the wrong time. Both the prehospital and in-hospital assessment, treatment, and times were all within acceptable parameters, but he simply exsanguinated from internal bleeding.
One new ED doc, who had spent the last decade of his life in the Iraq and Afghanistan war zones, asked a very good question: “I realize that normal saline temporarily fills up the vascular space, but it does not carry hemoglobin. How long did it take for the patient to get whole blood, and might it make more sense to teach the medics to start transfusion in the field?”
For me, this was illuminating. Read on to learn why it’s critical to teach first-responding paramedics about prehospital whole blood transfusions.
Prehospital blood transfusion and paramedic first response: A brief background
In the history of trauma, so much has been learned in the war zone. Bringing medics right up to the battlefield and training soldiers in first aid basics and how to apply a tourniquet are good examples of important teaching tips.
Also, we’ve learned the importance of time and the need for rapid helicopter evacuation to nearby surgical centers for stabilization, the application of traction splints, the proper application of hemostatic dressings, and the field use of blood products. These wartime lessons have made significant contributions to civilian life and EMS training, including:
- Trauma center designation
- National field triage guidelines
- Local and regional trauma treatment and transport protocols
- ATLS, BTLS, and PHTLS training courses
Exsanguination remains the leading cause of preventable deaths among victims of trauma, with nearly half of those patients dying in the prehospital setting.
Among military patients, prehospital transfusion within minutes of injury is associated with significantly reduced 24-hour and 30-day mortality. In fact, prehospital blood product resuscitation has demonstrated greater than predicted survival, with a 37 percent reduction in 30-day mortality among severely injured civilian patients.
Has your region considered blood transfusion in the field for major trauma?
According to the 2022 Joint Consensus Opinion Position Statement of the American College of Surgeons Committee on Trauma, the American College of Emergency Physicians, and the National Association of EMS Physicians, patients with signs of hemorrhagic shock should receive prehospital blood products whenever available. The preference for field use would be for whole blood as opposed to component blood products, such as packed red blood cells (PRBC), plasma, and platelets.
Additionally, The International Association of EMS Chiefs (IAEMSC) published a statement in August endorsing prehospital blood product transfusion by paramedics to treat acute hemorrhagic shock. Since the release of that statement, a prehospital blood transfusion initiative coalition is in the process of being formed.
Currently over 100 fire-based and single-service EMS agencies nationwide (including helicopter EMS services) have already begun developing programs for transfusion in the field. Typical indications include patients with a penetrating truncal mechanism, external signs of hemorrhage, and hemorrhage shock (that is, systolic BP < 90 mmHg, heart rate > 120 beats per minute).
Since most blood transfused in the field is usually type O, Rh positive, the system needs to address the issue of a pregnant patient whose fetus might be Rh negative. Despite the risks to the fetus, most systems have decided the benefits of the prehospital transfusion outweigh the risks and have a plan for the complications to be dealt with in the trauma center.
Managing volume resuscitation algorithm
According to NAEMT’s current tenth edition of Prehospital Trauma Life Support (PHTLS), the algorithm for volume resuscitation includes the following:
- In the management of patients with uncontrolled hemorrhage where it is suspected from as intrathoracic, intraabdominal, or retroperitoneal hemorrhage, the latest algorithm suggests use of blood products, as available, in Class III or IV shock to maintain a systolic BP of 80-90 mmHg.
- In the management of patients with a hemorrhage that includes a suspected CNS injury, the blood products, as available, should maintain a systolic BP of 110 mm Hg.
- In the management of patients with a controlled external hemorrhage and Class II, III, or IV shock, the blood products, as available, should maintain a systolic BP of 80 mm Hg.
Issues to consider when developing a program for paramedics in your region
Clearly there will be issues, but none are insurmountable and EMS agencies that already have programs in place should be able to share best practices. No need to reinvent the wheel here—pick up the phone!
Some issues to navigate might sound similar to issues we faced when we first started carrying analgesics and can include these:
- Your service medical director’s buy-in and support for the program
- Updating your state’s paramedic scope of practice
- Availability of the blood product supply from blood banks
- Training and protocols
- Ensuring an adequate supply while avoiding expiration waste
- Ensuring vehicles carrying blood products can maintain appropriate storage conditions
- Use of a blood warmer to deliver the product to the patient at 100°F (and no higher than 108°F)
- Reimbursement issues from government and commercial payors that need to cover the costs
- Protocols for tracking all units transfused as well as reporting any transfusion-related complications
Finally, perhaps some advocacy with the FDA may be in order to approve freeze-dried plasma, which is currently only approved for military use and might help with the costs and storage challenges of cold-stored blood products.
I have wondered in the recent past if that young gas station clerk would have survived had we carried blood products back in those days and of course dialed back the 2 liters of normal saline.
What can you do at your agency level?
- Do research on prehospital transfusion programs.
- Have an open discussion with your service medical director on the pros and cons of setting up a blood transfusion program in your service area.
- Review the trauma protocols, field trauma treatment guidelines, and transport to the Regional Trauma Center.
- Practice your trauma assessment and management skills with your team.
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About the author:
Bob Elling, MPA, Paramedic (retired), has been a career paramedic, educator, author, and EMS advocate since 1975. He was a paramedic with the Town of Colonie EMS Department, Albany Times Union Center, and Whiteface Mountain Medical Services. He was also an Albany Medical Center Clinical Instructor assigned to the Hudson Valley Community College Paramedic Program. Bob has served as National/Regional Faculty for the AHA and involved in many successful lifesaving legislative campaigns with the You’re the Cure Network. He also served as paramedic and lieutenant for New York City EMS, a paramedic program director, and the associate director of New York State EMS Bureau. He has authored hundreds of articles, videos, and textbooks to prepare EMS providers for their career. Bob is the ECSI Medical Editor for the CPR and First Aid Series and Co-Lead Editor of Nancy Caroline’s Emergency Care in the Streets.