Trauma and critical care surgeons discussed the vital role of prehospital blood in saving lives and offered solutions for promoting widespread adoption of this resuscitative intervention in Sunday’s session, “When Minutes Matter: Prehospital Transfusion for Traumatic Hemorrhage.”
Estimates suggest that a mere 2% of all US emergency medical services agencies currently carry blood products, with only 0.5% to 1% of the patients who meet the criteria for transfusion receiving prehospital transfusions.
Jason L. Sperry, MD, MPH, FACS, presented an overview of the evolution of prehospital resuscitation, highlighting several notable trials, including the Prehospital Air Medical Plasma (PAMPer) Trial, which showed that prehospital administration of thawed plasma had a 9.8% absolute reduction in 30-day mortality and improved blood clotting.
He also described the goals of the ongoing Type O Whole Blood and Assessment of AGE during Prehospital Resuscitation (TOWAR) Trial, which aims to assess the feasibility and efficacy of giving low-titer whole blood to trauma patients in an ambulance while enroute to a hospital. Dr. Sperry, a principal investigator for both trials, noted that the “early bird gets the worm,” underscoring that early prehospital interventions are indispensable for controlling blood lost and improving outcomes.
Shifting the focus to special populations, specifically pediatric patients and women of childbearing age, Christine M. Leeper, MD, FACS, noted that “bleeding is the leading cause of preventable death in children,” with mortality due to traumatic hemorrhagic shock affecting 36% to 50% of this patient cohort.
Dr. Leeper highlighted the results of supporting studies that have been conducted to date. “Prehospital transfusion is feasible, safe, and in some studies, is associated with increased survival for injured children compared with transfusion on arrival to the emergency department,” she explained.
Strategies for mitigating the risk of hemolytic disease for the fetus and newborn (HDFN) during an emergency transfusion in women of childbearing age also were outlined.
“Giving Rh+ blood to a female who is Rh- has the potential to result in alloimmunization and HDFN in a future pregnancy. Severe morbidity and mortality due to HDFN are almost entirely preventable with effective perinatal care,” she said, pointing out that Rh- whole blood is in very short supply. “We have an ethical obligation to mitigate this risk when feasible.”
Nakul Raykar, MD, MPH, FACS, offered two key messages in his presentation: “Blood transfusion is essential for life across a wide range of ailments and is not limited to trauma and obstetrics patients,” and “Prehospital blood can offer hope for hemorrhage for patient living in blood deserts.”
According to Dr. Raykar, “Non-trauma patients constitute up to 70% of patients who require prehospital blood.” These individuals include those suffering from gastrointestinal bleeding (42% to 70%), cardiovascular patients (18% to 30%), postsurgical patients (17% to 33%), and others (6% to 20%).
Timely transfusion is critical for every patient who requires it, regardless of injury or condition, but for those living in blood deserts, this intervention can be hours or even days away. Factors, including remote geography, underdeveloped blood banking infrastructure, and restrictive national policies, collectively perpetuate the existence of blood deserts. Estimates suggest that billions of individuals worldwide live in blood deserts. In the US, more than 100 million Americans live in regions that are more than 30 minutes from a blood bank.
Dr. Raykar gave some sobering state-specific examples of hospitals with a deficient blood supply, including Kansas, where 30% of critical access hospitals do not have a 24/7 blood bank, a reality compounded by staff shortages and a short supply of blood products. In Arkansas, only 16% of trauma centers have access to balanced blood resuscitation, according to Dr. Raykar.
“Prehospital blood can provide a critical bridge for hemorrhage in blood deserts, shortening time to transfusion and ensuring a robust pool of blood exists that travels to patients in need,” Dr. Raykar said.
Zain G. Hashmi, MD, FACS, offered his perspectives on urban versus rural disparities and the challenges that persist regarding wider implementation of prehospital blood transfusions in the US.
“Rural patients in shock spend 1 hour in the prehospital phase of care…16 more minutes than urban patients, and rural residents are 14% more likely to die within 24 hours versus urban patients,” said Dr. Hashmi, referring to these disparities as “the tyranny of time and distance.”
He acknowledged the prohibitive costs associated with establishing a prehospital blood transfusion program, with some estimates suggesting it can cost from $200 to $1,000 per transfusion, including expenses associated with blood products, consumables, and associated equipment. Typically, these costs are not directly reimbursed by the Centers for Medicare & Medicaid Services, but rather through bundled payment. Most programs are funded through federal, state, county, and city grants, foundation grants, and philanthropic gifts.
In addition to costs, another barrier to wider implementation of these programs comes in the form of regulatory hurdles, specifically state laws, which sometimes prohibit EMS providers from initiating blood transfusion. At one time, administering blood was considered beyond the scope of paramedics due to concerns regarding safety and qualifications, although advocates now consider these concerns to be outdated.
While significant barriers impeding the widespread implementation of prehospital blood programs are ongoing, the data suggest these interventions are a life-preserving measure for severely injured patients.
