According to data presented by the Prehospital Blood Transfusion Initiative Coalition, exsanguination remains the leading cause of preventable death amongst victims of trauma, with nearly half of these patients dying in the prehospital setting. The American College of Surgeons Committee on Trauma, the American College of Emergency Physicians, and the National Association of EMS Physicians recently released a joint statement recommending that the treatment of compressible hemorrhage focus on stopping the active bleeding and then replacing the blood lost through the prehospital transfusion of donated blood products (Barry et al., 2023). Multiple studies have focused on evaluating the importance of these strategies, specifically, the administration of blood products, and staggering statistics are coming to light. One study showed that every 1-minute delay in administration of these blood products or hemostatic agents was associated with a 2% increase in the odds of 30-day mortality (Barry et al., 2023).

Despite the mounting evidence surrounding the importance of this therapy, blood products have not been commonly available for transfusion in the prehospital setting in the United States. An evaluation of the National Emergency Medical Services Information System (NEMSIS) revealed that only 0.21% of the hypotensive trauma patients who were seen by EMS in the year 2019 received prehospital blood transfusions (Barry et al., 2023). Since then, several initiatives have been implemented to increase the availability of prehospital blood products. As of October 2024, 40 of the 50 states have initiated protocols that allow for the transfusion of blood products in place of crystalloid fluids. Crystalloids were found to result in increased mortality rates and increased incidence rates of multisystem organ dysfunction syndrome (MODS), acute respiratory distress syndrome (ARDS), and abdominal compartment syndrome when compared to patients who received blood product resuscitation (Colwell, 2024).

The Joint Trauma System’s Clinical Practice Guideline for Prehospital Blood Transfusions discusses multiple options for blood product transfusions, but three applications have gained mainstream traction: low titer whole blood, a combination of packed red blood cells and plasma, or just packed red blood cells. Gaining recognition as the gold standard in the resuscitation of hemorrhaging patients, low titer whole blood consists of multiple components of physiological blood: red blood cells, plasma, and platelets. These components replenish the hemoglobin levels (and therefore increase oxygen carrying capacity), volume, and clotting factors that patients lose when they bleed. This combination effectively mitigates metabolic acidosis and coagulopathy, two of the three components of the trauma triad that lead to the deterioration of most trauma patients. One unit of whole blood typically consists of approximately 500 mL of volume, but unfortunately, it has the shortest storage life of the recommended products, a little over 20 days from donation to expiration. It also requires that the donor be type O and have a low level of antibodies in their donation to reduce the risk of transfusion reaction (hence “low titer”).  Because of this, qualifying donations are somewhat rare, making a unit of low titer whole blood very expensive. Its cost-effectiveness can therefore be limited for prehospital application or non-tertiary care facilities (Hashmi et al., 2021).

If whole blood is not feasible or available, a 1:1 ratio of packed red blood cells (PRBCs) and plasma would be the next preferred option. This combination would be slightly limited in that it would only increase the patient’s hemoglobin and volume. The logistics of this application are also somewhat complicated because the storage life of a unit of plasma is different than a unit of PRBCs, making rotating the supply more cumbersome. If the plasma portion is not available, or an agency is looking to streamline the already complicated logistics of stocking, storing, and rotating different blood products, the recommendation would be to administer just the PRBCs.  The packed red cells will help stave off metabolic acidosis by increasing hemoglobin and oxygen carrying capacity but do little for the coagulopathy also commonly seen in true exsanguination. The benefits are that the storage life of a unit of PRBCs is twice as long as a unit of whole blood or fresh plasma, and they are one of the most readily available blood products. This makes their utilization in the prehospital arena much more responsible (Hashmi et al., 2021).

With very few exceptions, prehospital blood transfusions are uncross-matched, regardless of the product being transfused. This means that the transfusion occurs without testing the patient’s blood sample for reactions or even knowing the patient’s blood type. This requires that the blood being transfused is type O, which contains no A or B antigens that could potentially react with the patient’s existing antibodies. In an ideal world, all uncross-matched transfusions would utilize type O negative (O-) blood. Unfortunately, O- is a rare blood type, limiting the availability of these true “universal donor” units. Therefore, most facilities will utilize the next best thing, O positive (O+). This blood type only contains the Rh antigen. Given that approximately 84% of the population has an Rh-positive blood type, there is minimal likelihood of reaction. To further decrease the risk, an Rh-negative patient would have to have been exposed to Rh-positive blood in the past to develop the antibody for the Rh antigen. For this reason, special consideration should be given when deciding if uncross-matched transfusion of O+ products is warranted in children and women of childbearing age (Hashmi et al., 2021).

In conclusion, in caring for the bleeding patient every second matters. The administration of prehospital blood transfusion improves patient outcomes by addressing hemorrhagic shock in the most critical “golden hour.” The administration of blood products facilitates the rapid restoration of blood volume, and oxygen-carrying capacity, and the mitigation of the harmful effects of severe blood loss particularly in critically injured patients.  Its successful implementation requires careful consideration of protocols, the availability of required resources, and additional training for prehospital staff. Ongoing research, training, and implementation of programs are crucial to optimizing the use of prehospital blood transfusion in efforts to make this practice standard of care and save more lives!

 
References
Berry, C., Gallagher, J. M., Goodloe, J. M., Dorlac, W. C., Dodd, J., & Fischer, P. E. (2023). Prehospital Hemorrhage Control and Treatment by Clinicians: A Joint Position Statement. Prehospital emergency care, 27(5), 544–551. https://doi.org/10.1080/10903127.2023.2195487
 
Colwell, C. (2024, April 23). Initial management of moderate to severe hemorrhage in the adult trauma patient. UpToDate. https://www.uptodate.com/contents/initial-management-of-moderate-to-severe-hemorrhage-in-the-adult-trauma-patient
 
Deeb, A. P., Guyette, F. X., Daley, B. J., Miller, R. S., Harbrecht, B. G., Claridge, J. A., Phelan, H. A., Eastridge, B. J., Joseph, B., Nirula, R., Vercruysse, G. A., Sperry, J. L., & Brown, J. B. (2023). Time to early resuscitative intervention association with mortality in trauma patients at risk for hemorrhage. The journal of trauma and acute care surgery, 94(4), 504–512. https://doi.org/10.1097/TA.0000000000003820
 
Hashmi, Z. G., Chehab, M., Nathens, A. B., Joseph, B., Bank, E. A., Jansen, J. O., & Holcomb, J. B. (2021). Whole truths but half the blood: Addressing the gap between the evidence and practice of pre-hospital and in-hospital Blood Product Use for trauma resuscitation. Transfusion, 61 Suppl 1, S348–S353. https://doi.org/10.1111/trf.16515
 
 

 

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