Risk Management Analysis of Air Ambulance Blood Product Administration in Combat Operations

Powell-Dunford, Nicole; Quesada, José F.; Malsby, Robert F; Chou, Victoria B; Gerhardt, Robert T.; Gross, Kirby R.; Shackelford, Stacy

doi:10.3357/asem.3851.2014

Cited by 12 publications

(12 citation statements)

References 15 publications

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“…52–56 Finally, position papers from civilian and military thought leaders have been recently published, clearly stating the desire for prehospital blood products and high quality studies to determine their efficacy. 44– 51, 57, 58 In summary, a series of retrospective studies have shown associations with improved outcomes with blood product based resuscitation compared to crystalloid. However a recent comprehensive review of this subject by Smith et al has concluded that there is no effect, albeit the quality of all available data are very low.…”

Section: Discussionmentioning

confidence: 99%

Multicenter observational prehospital resuscitation on helicopter study

Holcomb

Swartz

et al. 2017

Journal of Trauma and Acute Care Surgery

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BACKGROUND Earlier use of in-hospital plasma, platelets and red blood cells (RBCs) has improved survival in trauma patients with severe hemorrhage. Retrospective studies have associated improved early survival with prehospital blood product transfusion (PHT). We hypothesized that PHT of plasma and/or RBCs would result in improved survival after injury in patients transported by helicopter. METHODS Adult trauma patients transported by helicopter from the scene to nine Level 1 trauma centers were prospectively observed from Jan–Nov 2015. Five helicopter systems had plasma and/or RBCs while the other four helicopter systems used only crystalloid resuscitation. All patients meeting predetermined high risk criteria were analyzed. Patients receiving PHT were compared to patients not receiving PHT. Our primary analysis compared mortality at 3 hours, 24 hours, and 30 days, using logistic regression to adjust for confounders and site heterogeneity to model patients who were matched on propensity scores. RESULTS 25,118 trauma patients were admitted, 2341 (9%) were transported by helicopter, of which 1058 (45%) met the highest risk criteria. 585/1058 patients were flown on helicopters carrying blood products. In the systems with blood available, prehospital median systolic blood pressure (125 vs 128) and GCS (7 vs 14) was significantly lower, while median ISS was significantly higher (21 vs 14). Unadjusted mortality was significantly higher in the systems with blood products available, at 3 (8.4% vs 3.6%), 24 (12.6% vs 8.9%) hours and 30 days (19.3% vs 13.3%). 24% of eligible patients received a prehospital transfusion. A median of 1 unit of RBCs and plasma were transfused prehospital. Of patients receiving PHT, 24% received only plasma, 7% received only RBCs and 69% received both. In the propensity score matching analysis (n=109), PHT was not significantly associated with mortality at any time point, although only 10% of the high risk sample were able to be matched. CONCLUSIONS Because of the unexpected imbalance in systolic blood pressure, GCS and ISS between systems with and without blood products on helicopters, matching was limited and the results of this study are inconclusive. With few units transfused to each patient and small outcome differences between groups, it is likely large, multicenter, randomized studies will be required to detect survival differences in this important population.

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Section: Discussionmentioning

confidence: 99%

Multicenter observational prehospital resuscitation on helicopter study

Holcomb

Swartz

et al. 2017

Journal of Trauma and Acute Care Surgery

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“…In military services, penetrating injuries were reported by 68% to 100% of studies and the mean or median ISS varied from 15 to 45 (Table ) . The most frequently reported mechanisms of injury were explosions (1%‐87%) and gunshot wounds (13%‐100%) …”

Section: Resultsmentioning

confidence: 99%

“…In military EMS, three observational studies analysed the change in vital parameters after transfusion, all showing improvements (significant rise in SBP and improvement in SI; a fall in HR; or a SBP closer to physiologically normal values as the prehospital transfused volume increased).…”

Section: Resultsmentioning

confidence: 99%

Pre‐hospital transfusion of red blood cells. Part 2: A systematic review of treatment effects on outcomes

Turenhout

Bossers

Loer

et al. 2020

Transfusion Medicine

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The primary aim of this systematic review is to describe the effects of prehospital transfusion of red blood cells (PHTRBC) on patient outcomes. Damage control resuscitation attempts to prevent death through haemorrhage in trauma patients. In this context, transfusion of red blood cells is increasingly used by emergency medical services (EMS). However, evidence on the effects on outcomes is scarce. PubMed and Web of Science were searched through January 2019; 55 articles were included. No randomised controlled studies were identified. While several observational studies suggest an increased survival after PHTRBC, consistent evidence for beneficial effects of PHTRBC on survival was not found. PHTRBC appears to improve haemodynamic parameters, but there is no evidence that shock on arrival to hospital is averted, nor of an association with trauma induced coagulopathy or with length of stay in hospitals or intensive care units. In conclusion, PHTRBC is increasingly used by EMS, but there is no strong evidence for effects of PHTRBC on mortality. Further research with study designs that allow causal inferences is required for more conclusive evidence. The combination of PHTRBC with plasma, as well as the use of individualised transfusion criteria, may potentially show more benefits and should be thoroughly investigated in the future. The review was registered at Prospero (CRD42018084658). K E Y W O R D Sdamage control resuscitation, emergency medical service, major haemorrhage, mortality, outcome, prehospital transfusion, red blood cells

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“…Modern helicopter transport teams are equipped with advanced resuscitation measures such as blood products 11. The patient had already received tranexamic acid at the local hospital.…”

Section: Discussionmentioning

confidence: 99%

“…Modern helicopter transport teams are equipped with advanced resuscitation measures such as blood products. 11 The patient had already received tranexamic acid at the local hospital. However, the local hospital had no blood products in stock, and the patient underwent a massive infusion without transfusion, leaving her severely anemic on arrival at our hospital.…”

Section: Uring Interhospital Air Evacuations Wherementioning

confidence: 99%

A system of delivering medical staff members by helicopter to manage severely wounded patients in an area where medical resources are limited

Ishikawa

Omori

Ohsaka

et al. 2016

Acute Medicine & Surgery

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AimWe review the case of a severely injured patient to evaluate the system of delivering medical staff by helicopter in areas with limited medical resources.MethodsThe patient's chart was reviewed, summarized, and presented.ResultsA 22‐year‐old woman attempted a suicidal fall after using a knife to stab herself. She was transported to a local hospital. A radiological study revealed fractures to the patient's face and the base of her skull, pneumocephalus, traumatic subarachnoid hemorrhage, stab wounds to the neck and chest, pneumothorax, unstable pelvic fracture, and right femoral shaft fracture. Her circulation status became unstable. We sent medical staff members to the local hospital by doctor helicopter. The patient underwent tracheal intubation and the insertion of a chest drain, and was evacuated by doctor helicopter. After aggressive intensive treatments in our hospital, the patient finally obtained social rehabilitation.ConclusionIn an area where medical resources are limited, sending trained physicians to a referring hospital to appropriately prepare a severely wounded patient for transportation might be the key for the patient to maximize his or her chance of survival.

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Risk Management Analysis of Air Ambulance Blood Product Administration in Combat Operations

Cited by 12 publications

References 15 publications

Multicenter observational prehospital resuscitation on helicopter study

Multicenter observational prehospital resuscitation on helicopter study

Pre‐hospital transfusion of red blood cells. Part 2: A systematic review of treatment effects on outcomes

A system of delivering medical staff members by helicopter to manage severely wounded patients in an area where medical resources are limited

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