The Implementation of a Prehospital Whole Blood Transfusion Program and Early Results

Abstract

Introduction: In far-forward combat situations, the military challenged dogma by using whole blood transfusions (WBTs) rather than component-based therapy. More recently, some trauma centers have initiated WBT programs with reported success. There are a few Emergency Medical Service (EMS) systems that are using WBTs, but the vast majority are not. Given the increasing data supporting the use of WBTs in the prehospital setting, more EMS systems are likely to consider or begin WBT programs in the future. Objective: A prehospital WBT program was recently implemented in Palm Beach County, Florida (USA). This report will discuss how the program was implemented, the obstacles faced, and the initial results. Methods: This report describes the process by which a prehospital WBT program was implemented by Palm Beach County Fire Rescue and the outcomes of the initial case series of patients who received WBTs in this system. Efforts to initiate the prehospital WBT program for this system began in 2018. The program had several obstacles to overcome, with one of the major obstacles being the legal team’s perception of potential liability that might occur with a new prehospital blood transfusion program. This obstacle was overcome through education of local elected officials regarding the latest scientific evidence in favor of prehospital WBTs with potential life-saving benefits to the community. After moving past this hurdle, the program went live on July 6, 2022. The initial indications for transfusion of cold-stored, low titer, leukoreduced O+ whole blood in the prehospital setting included traumatic injuries with systolic blood pressure (SBP) < 70mmHg or SBP < 90mmHg plus heart rate (HR) > 110 beats per minute. Findings: From the date of onset through December 31, 2022, Palm Beach County Fire Rescue transported a total of 881 trauma activation patients, with 20 (2.3%) receiving WBT. Overall, nine (45%) of the patients who had received WBTs so far remain alive. No adverse events related to transfusion were identified following WBT administration. A total of 18 units of whole blood reached expiration of the unit’s shelf life prior to transfusion. Conclusion: Despite a number of logistical and legal obstacles, Palm Beach County Fire Rescue successfully implemented a prehospital WBT program. Other EMS systems that are considering a prehospital WBT program should review the included protocol and the barriers to implementation that were faced.

Implementation of a prehospital whole blood program: Lessons learned

“…Given Howard County's population of 350,000, the risk of alloimmunization could be extrapolated to approximately one female of childbearing potential per 4.25 years. In addition, the experiences from other prehospital LTO+WB programs have also demonstrated that only a small fraction of the patients will be Rh‐negative females of childbearing potential and have described the risk of death from hemorrhage as far greater than the risk of isoimmunization 24–26 …”

“…In addition, the experiences from other prehospital LTO+WB programs have also demonstrated that only a small fraction of the patients will be Rh-negative females of childbearing potential and have described the risk of death from hemorrhage as far greater than the risk of isoimmunization. [24][25][26] LTO+WB contains low levels of anti-A and anti-B antibodies, making it safer for administration and less likely to cause a transfusion reaction despite being Rh+. 27 The THOR-AABB guidelines reference IgM anti-A and Ant-B levels as <256 as low titer.…”

Effect of major trauma on the expected number of births in Finnish women: A nationwide population‐based public data and register analysis

“…Unfortunately, only a small percentage of RBC and LTOWB donors are both group O and RhD‐negative. Since far more donors are RhD‐positive than RhD‐negative, 8 some centers use RhD‐positive group O RBCs and LTOWB to meet the needs of urgently bleeding patients whose blood group is unknown early in the resuscitation 9–11 …”