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Giving packed red blood cells in the prehospital phase of care...a good idea?

Errington Thompson errington at erringtonthompson.com
Mon Apr 9 13:55:10 BST 2012


Last night, I took care of a great patient. He is a 25 yo who was in a MVC.
No LOC. Pinned in the car for over 45 minutes. Was tachycardic in the field
but normotensive. He gets here and he is complaining of terrible back and
lower leg pain (see photo). His initial BP in the ER was 70. He gets a
central line and 2 units of PRBC. He has his work up and goes to the OR for
repair of his complex distal femur and proximal tibial fx's. (Back pain was
from transverse process fractures of the L spine)

Now, should he have gotten blood because he was tachycardic in the field?
Would that have changed his outcome or improved it?

A couple of years ago, there was a study (see attached) in which a single
episode of hypotension was associated with increased mortality and
morbidity. So, it would seem if this study is to be believed that we need to
do everything that we can to prevent hypotension including prehospital
transfusions. 

Errington C. Thompson, MD, FACS, FCCM
Trauma Surgeon/Surgical Critical Care
Radio Talk Show Host - Podcasts
Asheville, NC  

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of Karim Brohi
Sent: Monday, April 09, 2012 7:04 AM
To: Trauma-List [TRAUMA.ORG]
Subject: Re: Giving packed red blood cells in the prehospital phase of
care...a good idea?

E

You're correct - this is for a very small subset of patients.  However
clearly if one goal any advance in prehospital care is to reduce mortality,
then this is a group of patients to target, as they continue to have a
mortality of up to 30%

There are two conflicting goals here - perfusion and coagulation.  At the
moment we cannot monitor either and we treat one at the expense of the
other.  Permissive hypotension strategies sacrifice perfusion for
coagulation.  Prehospital resuscitation strategies in some parts of the
world sacrifice coagulation for perfusion.  There is no clear winner.

In London our protocols favour the permissive hypotension strategy (as a
part of damage control resuscitation).  However when we say 'in penetrating
trauma we would limit fluids' we are usually talking about patients who have
SBPs above (say) 70mmHg.  But do you ever let a patient with (say)
penetrating chest trauma sit at a blood pressure of 40mmHg till they get
into the operating room?  Or if you do, how low would you go before you
would give something - anything, to get a bit of perfusion??

Karim


On Sat, Apr 7, 2012 at 23:37, Errington Thompson
<errington at erringtonthompson.com> wrote:
> I find this fascinating. Fearing one on the prehospital ambulances
 
> Fascinating. I wonder what percentages of patients who would benefit 
> from prehospital administration of blood? From trauma standpoint, I 
> suspect were only talking about patients were victims of blunt trauma. 
> Of those, probably one or 2%, at most, would require prehospital blood 
> transfusion in order to stabilize their vital signs. Again, I'm just 
> guessing, that we would only be talking about patients who have 
> relatively prolonged prehospital transport times – >30 min.
>
> In our trauma center, here in Asheville, North Carolina, we see about 
> 3500 patients a year. About 400 patients with penetrating trauma. For 
> our code traumas, our highest activation, we used to have blood 
> available every time a code traumas activated. We stopped that. We 
> just don't transfuse that many patients. I guess, another way of 
> putting it, is that we just don't transfuse that many patients acutely.
>
> For patients with penetrating trauma, it would seem that we would like 
> to limit fluid into it and get the patient to the operating room. 
> Therefore, the vast majority of patients with penetrating trauma would 
> not receive any significant prehospital fluid/blood transfusions.
>
> I'm sure there's a way to look into the national trauma databank and 
> figure out which patients would possibly have benefited from 
> prehospital transfusions and what the numbers are. Again, I think this 
> would be fascinating. I look forward to some of the data that comes 
> out of this new protocol.
>
> Errington C. Thompson, MD, FACS, FCCM
> Trauma Surgeon/Surgical Critical Care
> Radio Talk Show Host - Podcasts
> Asheville, NC
>
>
> -----Original Message-----
> From: trauma-list-bounces at trauma.org 
> [mailto:trauma-list-bounces at trauma.org]
> On Behalf Of Dominik Krzanicki
> Sent: Saturday, April 07, 2012 4:23 AM
> To: Trauma-List [TRAUMA.ORG]
> Subject: Re: Giving packed red blood cells in the prehospital phase of 
> care...a good idea?
>
> I can clarify some of the logistics to allow the discussion to become 
> more clinical.
>
> London HEMS operate a Doctor-Paramedic model.
> 4 units of blood are carried on the helicopter and 4 units on the 
> rapid response vehicles.
>
> They are stored in 'Golden-Hour' boxes which have a data logger within 
> them to ensure temperature storage compliance. The blood is exchanged 
> every 24 hours when it re-enters hospital circulation (assuming 
> temperature storage conditions are acceptable) and therefore waste is 
> minimal. This also ensures that the HEMS team are equipped with 
> relatively 'fresh' blood. All blood is tracked to ensure 100% 
> traceability regardless of which of the trauma centres in London the
patient is admitted to.
>
> Administration is governed by SOP and discussed with an on-call 
> consultant prior to administration to ensure robust governance.
>
> As Karim said - huge undertaking to get this initiative operational 
> and a testament to those involved - well done.
>
>
> Dom - London HEMS registrar.
>
>
> On 7 Apr 2012, at 09:07, Karim Brohi wrote:
>
>> Marty
>>
>> My question related to patient care and how we might be able to 
>> improve survival.  If we determine that patients do better with a 
>> given intervention, then it is our duty to provide the clinical, 
>> logistic and legal frameworks that allow delivery of that care.
>>
>> You are not wrong to bring these issues up - much research is done 
>> and never implemented because of blocks at the implementation & 
>> policy phase.  However in this case we don't even know if it's the 
>> right thing to do yet - so let's talk about the science before we 
>> discuss practicalities.
>>
>> (BTW it took us 2 years to work out the logistics, regulatory issues, 
>> training and accountability issues to carry blood on the helicopter.
>> It's not something you'd get foisted with overnight!)
>>
>> Karim
>>
>> On Sat, Apr 7, 2012 at 01:26, Marty Munro <marty_munro at yahoo.ca> wrote:
>>> Mr. McSwain, I apologize for going astray, as it was my post that
> initiated it.  It is about the patient. However, EMS is a job for me. 
> I want a paycheque from it. If I only wanted to provide treatment, I 
> would work for free or for room and board. I always provide care to 
> the best of my ability within my scope of practice, but in the end, I 
> want to be paid, with as little risk as possible.
>>>
>>> It would be interesting to read some studies and hear from some 
>>> providers
> that have these directives in place. If anyone wishes to further 
> discuss issues that I have brought up, I welcome you to e-mail me
privately.
>>>
>>> Marty
>>>
>>> --- On Fri, 4/6/12, McSwain, Norman E <nmcswai at tulane.edu> wrote:
>>>
>>>
>>> From: McSwain, Norman E <nmcswai at tulane.edu>
>>> 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, 7:50 PM
>>>
>>>
>>> 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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>>>>> http://www.trauma.org/index.php?/community/
>>>>>
>>>>
>>>>
>>>>
>>>> --
>>>> 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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