Ground EMS units are dispatched to a rural portion of northern Minnesota for a single vehicle accident. North Memorial Air Care is auto-launched and responds to the scene. On arrival, EMS units find a female patient unconscious in her vehicle after crashing into a tree. The patient is found to be hypotensive, tachycardic and tachypneic. Her abdomen is bruised and warm. She’s packaged for transport to the nearest trauma center. En route, she receives 1 unit of packed red blood cells (PRBCs) in addition to standard fluid resuscitation and 1 gram of tranexamic acid (TXA) with improvement to her blood pressure, mentation and pulse rate.
Fluid resuscitation for prehospital trauma patients has changed incrementally in the past few years. The emphasis has shifted from aggressive volume replacement to the concept of permissive hypotension for several reasons.1-4 Among these, allowing mild hypotension in trauma patients has shown promise in decreasing mortality for hemorrhaging trauma patients. Evidence for permissive hypotension in patients with traumatic brain injuries is inconclusive.4 Crystalloid fluids simply replace lost volume with limited other benefits, can’t carry oxygen and don’t contain clotting factors. Until recently, the idea of administering blood in the prehospital environment was nothing more than a dream; however, the increased availability in blood storage and transport devices has made it a possibility.
PROCESS & ADMINISTRATION
The process of providing blood products to patients in need, and rotating a fresh stock, can be challenging for any EMS program; for North Memorial’s Air Care division this is no exception. With six bases of operations that are spread throughout Minnesota and Wisconsin, North Memorial Air Care is faced with a complex logistical challenge that’s tackled on a regular basis: Blood storage must be provided at a substantial distance from the central blood bank, and in-flight tools must allow for continuous temperature control for the blood products.
Furthermore, to ensure operational readiness, a process for replenishment of new blood units is required should another flight request come in. Meeting these challenges includes close coordination and a valued partnership with Memorial Blood Centers (MBC), a division of Innovative Blood Resources (IBC), which allows for this lifesaving resource to be provided to the public.
As part of the collaboration with MBC, training provided to flight crewmembers includes proper blood storage, review of Food and Drug Administration standards, and regulations for the proper handling, storing and transfusing of blood products.
As part of the process and incorporation of in-flight blood products as a service, North Memorial Air Care utilizes pre-established processes to order, store and monitor refrigerator temperatures remotely. Preconditioned blood refrigerators that have remote temperature monitoring capabilities are in place at each base with continuous surveillance. Monitoring and notification is set up at North Memorial Medical Center as well as through the North Memorial Communications Center, which notifies base coordinators and the on-call manager should there be a temperature variation outside the prescribed parameters.
When a flight request is received, flight crews pull two units of O-negative PRBCs from the storage refrigerator and pack them with the corresponding paperwork into a transport cooler. O-negative was chosen due to its ability to be transfused into any patient with minimal risks for transfusion reaction.
On scene arrival, flight crews assess for age-related signs of hypoperfusion (generally based on systolic blood pressure) due to acute blood loss in the setting of trauma, rupture of aortic aneurysm, or other atraumatic internal hemorrhage. On interfacility flights, provisions are added for physician orders or hemoglobin less than 7 mg/dL in the presence of a gastrointestinal bleed. Once criteria for blood administration have been met, PRBCs are hung with normal saline in standard Y-type blood tubing. In the setting of trauma, up to two units are administered using a pressure bag to adults, with weight-based dosing administered to pediatric patients under 40 kg until the systolic blood pressure returns to physiological parameters.
A single unit is administered to non-trauma patients with the availability to contact medical control to gain orders for additional units. All medical control requests are routed through the ED at North Memorial Medical Center, a Level 1 trauma center just outside of Minneapolis, for consistency. Because blood is dedicated to its own IV site, 1 gram of TXA is given following the completion of blood administration or through a secondary line.
Hemodynamic monitoring is required throughout the procedure and esophageal temperature probes are placed in all intubated patients for continuous monitoring of temperatures. All patients given blood are transported to tertiary receiving facilities located throughout the Upper Midwest and early notification of blood administration is done via radio while en route to the facility.
Following the flight, a standard blood administration tracking form is completed and attached electronically to the patient care record. Additionally, blood unit numbers are tracked within the patient care record and via the documentation provided with each unit of blood. The tracking segments attached to each unit of blood are given to the receiving facility for further testing. Additionally, all blood product administrations are tracked and reviewed by the quality committee and feedback is provided where indicated.
Should blood need to be given during a flight, and time permits, crews can contact the dispatch communication center or the on-call manager to help facilitate ordering of replenishment units to be delivered to North Memorial Medical Center. There, crews can pick up the new units once they’ve completed their flights and are returning to their bases. Additionally, blood can be ordered online, by phone or by fax while crews are at their home base. Blood delivery is coordinated with MBC and delivered to each of the bases on a rotating schedule. Deliveries are made by a hired courier service, an IBR (MBC) driver, or MBC volunteer. The blood is delivered in an insulated box that maintains the units of blood within a specified temperature range, preventing damage and spoilage for well over 24 hours. Once received, crews check in the new units of blood for base storage and return the unused stock of blood to MBC, thus preventing waste.
In the setting of trauma, up to two units of blood are administered to adults using a pressure bag.
IMPLEMENTATION & EDUCATION
After entering an agreement with MBC, we started acquiring equipment. The storage and transport of blood products requires very tight temperature control and monitoring. Blood product-approved refrigerators that have remote monitoring provided by the engineering department at our hospital allows for around-the-clock monitoring of the blood product storage. The temperature of the blood products are validated every time they’re removed or returned to the refrigerator with a precise thermometer that’s been validated to be accurate within 0.2 degrees C.
When the blood products leave the refrigerator, they’re transported in a cooler that has a complexly designed ice pack. This ice pack ensures the blood products don’t get too warm or too cold for up to 18 hours in the cooler. The ice packs have to be “recharged” in a freezer every 12 hours.
As the equipment was being procured and installed, we also developed a number of forms and processes for the transport, storage, administration and documentation of blood transfusion. In addition, our medical directors researched and developed specific protocols for the administration of blood products. Although traumatic injury is the most frequent need for PRBCs in the prehospital environment, there are other indications. There are hospitals in the most rural regions of our service area that don’t have blood banks. Also, there are times when the administration of blood within the hospital isn’t practical. Therefore we have protocols for the administration of PRBCs in select medical settings (e.g., gastrointestinal bleed and peripartum hemorrhage). The administration of PRBCs isn’t without risk, and our protocols are robust, with multiple clinical criteria to ensure we’re administering blood to the patients who would receive the most benefit.
The last piece in the process of implementing blood products involved training the staff. The didactic portion of the training was done via our online learning management system (LMS). This training started with basic concepts of blood type, Rh factor, blood components and how blood is collected. The training also included complex concepts such as blood transfusion reactions, host vs. graft disease, and transfusion-related lung injury.
In addition to didactic education via the LMS, hands-on training for the equipment was also provided. Blood transfusion sets and burettes with fake units of blood gave staff the tactile experience of spiking a blood set, manipulating the various flow controls and flushing the filter. In the same training session, we had multiple patient scenarios with manikins and real-time patient monitors that included the initiation of blood products and a blood transfusion reaction. The scenario-based education married the didactic education with the tactile skill, and incorporated clinical decision-making with the application of these protocols.
When the blood products leave the refrigerator, they’re transported in a cooler that has a complexly designed ice pack that keeps an optimal temperature for 18 hours.
Since the inception of blood product use in our aircraft, we’ve reviewed each field-initiated blood transfusion at our regular quality meeting with the medical directors, to ensure protocol compliance and evaluate the effectiveness of the transfusions. To date, we’ve administered blood products to dozens of patients without any adverse side effects. The success of this program is a direct result of extensive planning, robust protocols, multifaceted training and continuous quality review and feedback. Although North Memorial Air Care certainly isn’t the first air medical service to implement a blood product administration process in the prehospital environment,2 we appreciate the opportunity to share our experiences.
1. Bickell WH, Wall MJ Jr, Pepe PE, et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. New Eng J Med. 1994;331(17):1105-1109.
2. Holcomb JB, Donathan DP, Cotton BA, et al. Prehospital transfusion of plasma and red blood cells in trauma patients. Prehosp Emerg Care. 2015;19(1):1-9.
3. Savage SA, Fabian TC. Damage control strategies in the management of acute injury. Europ J Trauma Emerg Surgery. 2014;40(2):143-150.
4. Vrettos T, Poimenidi E, Athanasopoulos P, et al. The effects of permissive hypotension in combined traumatic brain injury and blunt abdominal trauma: An experimental study in swines. Eur Rev Med Pharmacol Sci. 2016:20(4):620-630.
• CRASH-2 trial collaborators, Shakur H, Roberts I, et al. Effects of tranexamic acid on death, vascular occlusive events and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): A randomized, placebo controlled trial. Lancet. 2010;376(9734):22-32.
• Ponschab M, Schöchl H, Keibl C, et al. Preferential effects of low volume versus high volume replacement with crystalloid fluid in a hemorrhagic shock model in pigs. BMC Anesthesiol. 2015;15:133.