When prehospital blood storage goes bad…

Auckland HEMS is currently exploring the use of blood products in our prehospital environment.

Two interesting papers regarding prehospital blood product use were recently published by the Queensland Ambulance Service. The Queensland Ambulance Service maintains a 24/7 doctor/paramedic trauma response team that is dispatched to significant trauma cases in the greater Brisbane area.

Despite the fact that the prehospital service in these studies is road-based, the patient cohort (predominantly blunt trauma), prehospital staffing (often initially ambulance crew followed by doctor/paramedic team), and prehospital times are highly applicable to our service.

The feasibility of civilian prehospital trauma teams carrying and administering packed red blood cells

This paper examined the feasibility, limitations, and costs involved in providing prehospital trauma teams with blood products (2 units of O-negative red cells)

• Of 500 units of RBCs provided to the service over 18 months, 26% were transfused
• 97.8% of non-transfused units were returned to the blood bank and were available for reissue
• The wastage rate of RBC units was 1.6%, which compares favourably with emergency department data
• The cost per unit transfused was calculated at $A551
• Stringent logistical and clinical governance was require to ensure that RBC units were stored, exchanged, and used appropriately

Characteristics and outcomes of patients administered blood in the prehospital environment by a road based trauma response team

• During the same 18 month period above, the trauma response team was activated 1584 times
• 719 of these patients had interventions performed that were outside the Intensive Care Paramedic scope of practice
• 73 patients required transfusion, 71 of which were for haemorrhagic shock due to trauma
• Trauma patients who required transfusion were severely injured, with a median ISS of 32
• 73% of these trauma patients had a blunt mechanism, most commonly due to MVA
• 72% of these trauma patients had a prehospital ultrasound, 40% of these were FAST positive; positive FAST scan prehospital was associated with a significantly faster time to definitive intervention after arrival at hospital
•  82% of patients who received RBCs prehospital required more blood products after arrival to hospital, 26% required massive transfusion
• No patient with an RTS less than 2 survived
• Mean prehospital time was 64 minutes

On average, patients had access to RBCs 45 minutes before their hospital arrival. Survival of patients who received prehospital RBCs was 3.6% higher than predicted by TRISS, with the authors stating that there ‘may be a survival benefit’. They also concluded that an RTS less than 2 (can be calculated based on prehospital vital signs) may indicate that transfusion is futile.

Click HERE for access to the full-text pdfs (secure area limited to ADHB staff only – ADHB has online subscription access to this journal)