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Prehospital blood transfusion

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Prehospital blood transfusion

  1. 1. 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
  2. 2. 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
  3. 3. Case - Paul
  4. 4. 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
  5. 5. 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
  6. 6. 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?
  7. 7. Coagulopathy in trauma • Medical • Bleeding diathesis • Anticoagulants • Trauma induced coagulopathy • Acute traumatic coagulopathy (↑TM/APC → ↓V/VIII and ↑fibrinolysis) • Hypothermia • Acidaemia • Dilutional
  8. 8. Why not use blood prehospital? • • • • • • Expense Short shelf half-life Difficult storage Wastage Tracking transfused patients Generic concerns re. blood transfusions
  9. 9. 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
  10. 10. SOP and good clinical governance
  11. 11. 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
  12. 12. Results • 158 missions were identified, of which 147 patient’s data sets were complete • 69.3% male with median (IQR) age of 34.5 (2252) • 382 units of PRBCs were transfused to 147 trauma patients (median 3u, range 1-6u) • Acceptable wastage (66u) • No documented transfusion reactions
  13. 13. 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 Number of patients trapped on arrival (%) 87 (59.1) 20 (13.6) 9 (6.1) 9 (6.1) 5 (3.4) 6 (4.1) 11 (7.5) 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) RTSc2, median (IQR) Volume of crystalloid given in ml, median (IQR) Pronounced life extinct on scene 5.967 (4.083-6.904) 500 (0-1500) 22 (15.0)
  14. 14. Intervention Total (n=147) Rapid sequence intubation 96 (65.3) Cold endotracheal intubation 15 (10.2) Surgical airway Thoracostomy (Open or tube) Thoracotomy 1 (0.7) 59 (40.1) 3 (2.0) Pelvic binder or fracture splintage 89 (60.5) Intraosseous insertion 22 (15.0) Humerus Tibia Femur Tourniquet application Positive E-FAST o o o Abdominal free fluid Pneumothorax Haemothorax 19 10 1 15 (10.2) 18/27 15 4 1
  15. 15. 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
  16. 16. Questions?

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