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Giving packed red blood cells in the prehospital phase ofcare...agood idea?

Duchesne, Juan C jduchesn at tulane.edu
Sun Apr 8 01:24:41 BST 2012


Karim-
I believe most paramedics out there have a good sense of which patients are on extremes and in need of pRBC and or plasma. The benefits of having an objective criteria is that it will help inexperience/new paramedics a quick on/off desicion making tool on when or who the activation transfusion protocol should be administered. (with or without FAST)

Regarding this case: 

> So patient with a BP of 70 systolic and, say a crushed pelvis (no TBI)
> - 45 minutes from the trauma centre.   Start transfusing now or not?
> SBP of 50?  30?  0?

In this specific case with massive tissue injury in combination with tissue hypo perfusion there is a high likelihood this patient will present to the ED with signs of ACoTS. That plus long transport time will increase his mortality > 50%. For that reason (besides a good pelvic binder) this patient should received a close ratio of plasma to pRBC by EMS until arrival to ED for angio/ surgical control . 
 Good case 

Duchesne 

Sent from my iPhone from Spirit of Charity Trauma Center, NOLA


On Apr 7, 2012, at 3:13, "Karim Brohi" <karim at trauma.org> wrote:

> Juan
> 
> The ABC score (which I'm not overly fond of) and similar tools predict
> the likelihood of massive transfuion based on physiology (+FAST!) on
> hospital arrival.   Of course they've not been validated for the
> prehospital setting (even if you have ultrasound prehospital)
> 
> Also, if you only have red cells, who should you start transfusing in
> an environment where you can't do haemorrhage control and have no
> plasma etc?  We know PRBC administration leads to (futher) dilutional
> coagulopathy (though of course less so than crytalloid/colloid).
> 
> So patient with a BP of 70 systolic and, say a crushed pelvis (no TBI)
> - 45 minutes from the trauma centre.   Start transfusing now or not?
> SBP of 50?  30?  0?
> 
> Karim
> 
> 
> On Sat, Apr 7, 2012 at 02:43, Duchesne, Juan C <jduchesn at tulane.edu> wrote:
>> That sounds very exiting Karim. Congrats!
>> -Regarding when to use a pre-hospital transfusion protocol- i will base my decision on ABC score (Cotton etal)
>> -Regarding your question about PRBC or plasma-I don't believe there is a straight right answer. Administration of PRBC and plasma by EMS providers in a close ratio fashion should improve coagulation and perfusion homeostasis
>> for the time needed prior to surgical correction of bleeding.
>> BUT at the same time while vigorous infusion of this valuable resources go into the patient with severe hemorrhage,  inevitably an increase in patient systolic pressure above 90 mmHg enough to potentially "pop the clot" might occur. In other words a quick scoop and run Is imperative for patients with severe hemorrhage.
>> Cheers
>> My 2 cents
>> Duchesne
>> 
>> Sent from my iPhone from Spirit of Charity Trauma Center, NOLA
>> 
>> 
>> On Apr 6, 2012, at 18:56, "McSwain, Norman E" <nmcswai at tulane.edu> wrote:
>> 
>>> I think that we have gone astray
>>> It is not about the providers, the EMS systems or the hospitals
>>> It IS about the patient
>>> 
>>> Let's address the science and then we can work out the process problems
>>> 
>>> The question Kiram asked is: "Will RBC given in the field be beneficial
>>> to the patient?"
>>> 
>>> Norman
>>> 
>>> Professor, Tulane University, Surgery
>>> Trauma Director, Spirit of Charity Trauma Center, ILH/MCLNO
>>> New Orleans, Louisiana
>>> 504 988 5111
>>> 
>>> 
>>> -----Original Message-----
>>> From: trauma-list-bounces at trauma.org
>>> [mailto:trauma-list-bounces at trauma.org] On Behalf Of johnleslie48
>>> Sent: Friday, April 06, 2012 6:36 PM
>>> To: Trauma-List [TRAUMA.ORG]
>>> Subject: Re: Giving packed red blood cells in the prehospital phase of
>>> care...a good idea?
>>> 
>>> Well said!
>>> 
>>> John Leslie
>>> 
>>> 0412 528851
>>> 
>>> Sent from my iPhone
>>> 
>>> On Apr 7, 2012, at 6:45, Marty Munro <marty_munro at yahoo.ca> wrote:
>>> 
>>>> Speaking as a paramedic, I would not want this responsibility. It's
>>>> just one more thing to go wrong in an often unstable environment, and
>>> one more reason for me to lose my certification, job, or be sued. We are
>>> always taught to limit our scene times in traumas and provide required
>>> care en route, for obvious reasons. This means that often, we are unable
>>> to establish an I.V. due extreme movement of the vehicle, accessibility
>>> of available veins and the requirement to maintain a patent airway as a
>>> priority. Therefore, arriving at the emergency department/trauma room in
>>> a timely manner is a medic's priority. There is conflicting evidence as
>>> to whether or not a fluid bolus is even beneficial, and evidence that
>>> suggests it is harmful to the trauma patient. So now, if medics start
>>> carrying blood, will they be expected to always have blood running en
>>> route to the hospital? And when they are unable to, suddenly the topic
>>> becomes "the patient could have survived had the paramedics started an
>>> I.V. and given blood en route".  The law suit begins, the medics lose
>>> their certifications and become the subject of an investigation and
>>> inquest.  And if they do start an I.V. and give blood and the patient
>>> dies, the topic becomes "paramedics wasted time by starting blood en
>>> route to the hospital". I am all for progressive medicine in the
>>> pre-hospital care, but I think that those who choose to implement
>>> certain things should try this first. Next time a trauma comes in to the
>>> hospital, instead of going to the nice bright trauam room, the patient
>>> should be taken into a utility closet, with only one physician and one
>>> extra person and all the care should be provided in a cramped closet by
>>> the single person while the extra person continuously shakes the
>>> mattress of the bed. Then think about how realistic/beneficial adding in
>>> extra skills/procedures is to pre-hospital staff. That's just my
>>> opinion.
>>>> 
>>>> Marty Munro
>>>> Advanced Care Paramedic
>>>> Ontario, Canada
>>>> 
>>>> 
>>>> 
>>>> --- On Fri, 4/6/12, Stephen Richey <stephen.richey at gmail.com> wrote:
>>>> 
>>>> 
>>>> From: Stephen Richey <stephen.richey at gmail.com>
>>>> Subject: Re: Giving packed red blood cells in the prehospital phase of
>>> care... a good idea?
>>>> To: "Trauma-List [TRAUMA.ORG]" <trauma-list at trauma.org>
>>>> Received: Friday, April 6, 2012, 3:25 PM
>>>> 
>>>> 
>>>> For the most part, I would say no at least here in the US since the
>>>> average level of education for a paramedic leaves much to be desired
>>>> (speaking as a former EMS educator myself).  The issues with quality
>>>> control, supply maintenance, the need to determine clinical need (EMS
>>>> providers tend to massive over-estimate the severity of patients'
>>>> conditions because most of them are taught "cookbook" defensive
>>>> medicine) and cost.  I am not sure how the blood banking situation is
>>>> in other countries but here there are often region-wide shortages of
>>>> blood products so the sequestration of a significant amount in the
>>>> hands of EMS providers would probably only exacerbate the situation.
>>>> 
>>>> Also, the problem is worsened by the fact that the patients who would
>>>> probably benefit most from field transfusions are the ones in the
>>>> areas least suited to its use because of administration, training and
>>>> supply issues.  Rural EMS tends to be almost all volunteer and many of
>>> 
>>>> these folks never even meet their medical director let along receive
>>>> any meaningful QA/QI feedback.  The idea of giving the blood to the
>>>> local HEMS operators and using them to deliver a higher level of care
>>>> isn't going to work because you're going to delay the arrival of the
>>>> patient in the OR in all but the most remote of areas.
>>>> 
>>>> In urban settings, you're not going to have that much need for
>>>> transfusion because of the proximity to trauma centers.  Here for
>>>> example, it's abnormal for EMS providers (such as my fiancee) to take
>>>> longer than 20 minutes from call to arrival at the hospital.
>>>> 
>>>> On Fri, Apr 6, 2012 at 3:12 PM, Karim Brohi <karim at trauma.org> wrote:
>>>> 
>>>>> So our trauma helicopter emergency medical service recently started
>>>>> carrying packed cells:
>>>>> http://www.bbc.co.uk/news/health-17232529
>>>>> 
>>>>> We'll obviously be auditing its use closely, but I'm interested in
>>>>> garnering the lists opinions on this:
>>>>> Who should get PRBCs?
>>>>> Should anyone get PRBCs?
>>>>> Why aren't we carrying plasma as well?
>>>>> 
>>>>> There are a couple of prehospital services in the US carrying blood
>>>>> and plasma to my knowledge, and it is used by MERT teams in combat
>>>>> zones.
>>>>> 
>>>>> So??
>>>>> 
>>>>> Karim
>>>>> --
>>>>> trauma-list : TRAUMA.ORG
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>>>>> 
>>>> 
>>>> 
>>>> 
>>>> --
>>>> Stephen Richey
>>>> Founder and Chief Researcher/Designer
>>>> Kolibri Aviation Safety Research
>>>> 5174-B Winterberry Circle
>>>> Indianapolis, IN 46254
>>>> 317-985-4740
>>>> 
>>>> "I think the best thing, and the only thing in our infinite inadequacy
>>> 
>>>> in making up for the loss of life, is to say something we have been
>>>> able to say in a lot of other accidents to grieving families.  That is
>>> 
>>>> 'Those deaths will not be in vain. We will not let them be in vain.
>>>> Every one of those lives will be made to count in terms of making sure
>>> 
>>>> that three, four, five or ten other people do not die."- John J. Nance
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