Resident Eagle: Whole Blood in the Rural EMS Environment

Resident Eagle is a monthly column profiling the work of top EMS physicians and medical directors from the Metropolitan EMS Medical Directors Global Alliance (the "Eagles"), who represent America’s largest and key international cities. Tentative dates for Gathering of Eagles 2021: June 14–18, Hollywood, Fla. For more see useagles.org.

You are dispatched to an early-morning call to a long-term care facility for a 71-year-old male with severe bleeding. Upon arrival you find a semiconscious elderly male lying supine in a blood-soaked bed. 

Prior to EMS arrival the patient had significant bleeding from a dialysis shunt in his left upper arm. Staff applied a pressure dressing and stopped the bleeding. Nursing staff noted blood-soaked sheets and called 9-1-1. They estimated his blood loss in excess of 1,000 mL. 

Initial assessment reveals altered mental status (alert to painful stimulus), weak carotid pulse, and pale, cool, and diaphoretic skin. The patient has a past medical history of diabetes mellitus, hypertension, and end-stage renal disease requiring hemodialysis, which he had completed earlier in the morning. Initial vital signs are BP 54/30, HR 88, RR 12, SpO₂ 94% on room air, EtCO₂ 22 mmHg, and compensatory reserve index 0.3. The patient is confirmed as experiencing hemorrhagic shock and meets criteria for a transfusion of low-titer O-positive whole blood (LTOWB).

Your crew notifies the EMS supervisor, who heads to the scene. A secondary assessment and repeat vital signs reaffirm the patient is a candidate for prehospital emergency transfusion. As you initiate IV access, the supervisor arrives with one unit of LTOWB. To prepare for transfusion, you confirm the product type, prime the blood filter tubing, and connect to a warming device. You initiate transfusion and prepare for transport. 

In your rural setting the local hospital is not staffed with vascular surgeons or interventional radiology specialties. You quickly confirm with your partner that the patient requires vascular intervention not available in your service area. The facility of choice is 68 miles away. Due to poor weather, a helicopter is not available. You thus begin ground transport to the hospital with specialists.

During transport you continue to reassess the site of blood loss and find the pressure dressing is providing adequate hemorrhage control. While the whole blood transfusion continues, you obtain additional IV access and administer tranexamic acid (TXA) for antifibrinolytic therapy. Repeat neurovascular assessment of the injured extremity shows no pulse, motor, or sensory changes. The whole blood transfusion completes within approximately 10 minutes, and you note marked improvements in hemodynamics (including increases in systolic blood pressure and EtCO₂) and the patient’s mental status. 

Discussion

Historically, prehospital patients presenting in hemorrhagic shock have been difficult to manage due to the lack of appropriate damage-control resuscitation intervention options. Current prehospital care is focused on stopping the bleeding, maintaining airway patency, ventilation, and circulatory support via IV crystalloid.¹ In recent years permissive hypotension (in the absence of traumatic brain injury) has also become acceptable. But numerous military and civilian research studies have shown crystalloids carry significant downstream consequences, including acidosis, hypothermia, and coagulopathy.² Blood products may provide a better alternative and aid providers in attempting to correct coagulopathy and restore perfusion to vital organs. 

Recent helicopter EMS trials have found prehospital transfusion of blood products (in this report plasma) yielded significant improvements in 30-day mortality when compared to traditional IV crystalloid.³ In the ground prehospital community, blood products are believed to benefit patients, but many questions and challenges still exist, as well as a lack of strong supporting evidence.

Whole blood transfusion is by no means a new concept. Fresh whole blood was historically transfused in the military setting due to availability of donors and its ease of use. Over the recent years whole blood, more specifically LTOWB, is regaining traction in the trauma community and showing favorable outcomes opposed to component therapy.⁴ Medical directors, EMS leaders, and prehospital care clinicians are looking for blood products that provide the easiest and safest method of blood replacement. LTOWB contains all blood components (i.e., red blood cells, plasma, platelets, etc.) in a single bag, as well as being sourced from a single donor (potentially lowering the risk of transfusion reactions). Cold-stored WB has shown to have improved function compared to 1:1:1 component therapy.⁴ 

In January 2018 the Air Medical Provider Advisory Group (AMPAG) of the Southwest Texas Regional Advisory Council (STRAC) collaborated with the South Texas Blood and Tissue Center and University Hospital to initiate the country’s first ever regional deployment of LTOWB. It was deployed across the 22-county region utilizing established HEMS providers.

Following its initial success, STRAC expanded the program to include ground EMS organizations. In October 2018 the San Antonio Fire Department joined the coalition with a deployment strategy for the urban environment.⁵ Now more than 30 air and ground EMS assets are equipped with LTOWB in the STRAC region. Multiple improved outcomes and/or saves have been seen since the program’s inception. Early results indicate a significant reduction in mortality in patients receiving LTOWB as opposed to traditional component therapy (18.8% vs. 76%).⁶  

Carrying Considerations

Factors for agencies to consider when considering carrying whole blood include call types/volume and proximity to definitive care. Agencies having increased transport times may benefit most from more aggressive care. Regardless, maintaining the core concepts of remote damage control resuscitation in patients presenting in hemorrhagic shock, along with a commitment to rapid transport to definitive care, has proven to be successful.⁵  

Logistical issues are likely more complex to overcome. Support from your regional healthcare system(s), agency leadership, municipality/government, physician partners, and lay public are keys to success. Though a single agency can attempt to forge its own path, a collaborative movement allows the ability to share costs and reduce waste. Donated blood product can be rotated near the end of its shelf life to an area or system where the highest potential for transfusion exists. This concept has proven to be successful in the San Antonio region, producing a monthly waste rate of just 1%–2%.

Commitment by far is the most important item within this chain of success. An EMS agency must be committed to: 1) procuring the appropriate equipment for storage of the blood product; 2) developing a rigorous program for continuous temperature monitoring; 3) procuring a device capable of warming the blood product for administration; 4) developing clinical guidelines for transfusion as well as initial and ongoing training; and 5) developing and implementing a quality assurance program with physician oversight to ensure good clinical practice.

Case Resolution

As transport continues, reassessment of the patient finds no signs or symptoms of a transfusion-related reaction. Care remains focused on prevention of hypothermia, acidosis, and coagulopathy. At the receiving hospital the patient receives subsequent transfusions of blood products while in the emergency department and has a surgical repair of his left upper arm via fistulogram with balloon angioplasty of the peripheral dialysis shunt.  

References

1. Udeani J. Hemorrhagic Shock Treatment and Management. Medscape, https://emedicine.medscape.com/article/432650-treatment.

2. Holcomb JB, Jenkins D, Rhee P, et al. Damage control resuscitation: directly addressing the early coagulopathy of trauma. J Trauma, 2007 Feb; 62(2): 307–10.

3. Sperry JL, Guyette FX, Brown JB, et al. Prehospital Plasma During Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock. N Engl J Med, 2018; 379(4): 315–26.

4. Spinella PC, Pidcoke HF, Strandenes G, et al. Whole blood for hemostatic resuscitation of major bleeding. Tranfusion, 2016 Apr; 56 Suppl 2: S190–202.

5. Bartikoski S. Weymouth W, Winckler CJ. Whole Blood in Trauma: Ready for Primetime? emDocs, 2019 Mar 18; www.emdocs.net/whole-blood-in-trauma-ready-for-primetime/.

6. Jenkins D. Pre-hospital Whole Blood. Southwest Texas Regional Advisory Council, www.strac.org/files/Research/AMPAG_Whole_Blood_09_2018.pdf.

Casey Ebrom, EMT-P, FP-C, is assistant EMS director for Karnes County EMS in South Texas. 

Craig Manifold, DO, FACEP, FAAEM, FAEMS, is medical director for the National Association of Emergency Medical Technicians. 

Randi Schaefer, MSN, RN, ACNS-BC, CEN, is director of the Southwest Texas Regional Advisory Council’s Research Division.