Kathleen S. Berns

The effects of prehospital plasma on patients with injury: a prehospital plasma resuscitation.

BACKGROUND The prehospital resuscitation of the exsanguinating patient with trauma is time and resource dependent. Rural trauma care magnifies these factors because transportation time to definitive care is increased. To address the early resuscitation needs and trauma-induced coagulopathy in the exsanguinating patient with trauma an aeromedical prehospital thawed plasma–first transfusion protocol was used. METHODS Retrospective review of trauma and flight registries between February 1, 2009, and May 31, 2011, was performed. The study population included all patients with traumatic injury transported by rotary wing aircraft who met criteria for massive transfusion protocol RESULTS A total of 59 patients identified over 28 months met criteria for initiation of aeromedical initiation of prehospital blood product resuscitation. Nine patients received thawed plasma–first protocol compared with 50 controls. The prehospital plasma group was more commonly on warfarin (22 vs. 2%, p = 0.036) and had a greater degree of coagulopathy measured by international normalized ratio at baseline (2.6 vs. 1.5, p = 0.004) and trauma center arrival (1.6 vs. 1.3, p < 0.001). The prehospital plasma group had a predicted mortality nearly three times greater than controls based on Trauma and Injury Severity Score (0.24 vs. 0.66, p = 0.005). The use of prehospital plasma resuscitation led to a plasma–red blood cell ratio that more closely approximated a 1:1 resuscitation en route (1.3:1.0 vs. not applicable, p < 0.001), at 30 minutes (1.3:1.0 vs. 0.14:1.0, p < 0.001), at 6 hours (0.95:1.0 vs. 0.42:1.0, p < 0.001), and at 24 hours (1.0:1.0 vs. 0.45:1.0, p < 0.001). An equivalent amount of packed red blood cells were transfused between the groups. Despite more significant hypotension, less crystalloid was used in the prehospital thawed plasma group, through 24 hours after injury (6.3 vs. 16.4 L, p = 0.001). CONCLUSION Use of plasma-first resuscitation in the helicopter system creates a field ready, mobile blood bank, allowing early resuscitation of the patient demonstrating need for massive transfusion. There was early treatment of trauma-induced coagulopathy. Although there was not a survival benefit demonstrated, there was resultant damage control resuscitation extending to 24 hours in the plasma-first cohort. LEVEL OF EVIDENCE Therapeutic study, level IV.

Implementation and execution of civilian remote damage control resuscitation programs

ABSTRACT Remote damage control resuscitation is a recently defined term used to describe techniques and strategies to provide hemostatic resuscitation to injured patients in the prehospital setting. In the civilian setting, unlike the typical military setting, patients who require treatment for hemorrhage come in all ages with all types of comorbidities and have bleeding that may be non–trauma related. Thus, in the austere setting, addressing the needs of the patient is no less challenging than in the military environment, albeit the caregivers are typically not putting their lives at risk to provide such care. Two organizations have pioneered remote damage control resuscitation in the civilian environment: Mayo Clinic and Royal Caribbean Cruises Ltd. The limitations in rural Minnesota and shipboard are daunting. Patients who have hemorrhage requiring transfusion are often hundreds of miles from hospitals able to provide damage control resuscitation. This article details the development and implementation of novel programs specifically designed to address the varied needs of patients in such circumstances. The Mayo Clinic program essentially takes a standard-of-care treatment algorithm, by which the patient would be treated in the emergency department or trauma bay, and projects that forward into the rural environment with specially trained prehospital personnel and special resources. Royal Caribbean Cruises Ltd has adapted a traditional military field practice of transfusing warm fresh whole blood, adding significant safety measures not yet reported on the battlefield (see within this Supplement the article entitled “Emergency Whole Blood Use in the Field: A Simplified Protocol for Collection and Transfusion”). The details of development, implementation, and preliminary results of these two civilian programs are described herein.

Needle thoracostomy: Clinical effectiveness is improved using a longer angiocatheter.

BACKGROUND Decompression of tension physiology may be lifesaving, but significant doubts remain regarding ideal needle thoracostomy (NT) catheter length in the treatment of tension physiology. We aimed to demonstrate increased clinical effectiveness of longer NT angiocatheter (8 cm) compared with current Advanced Trauma Life Support recommendations of 5-cm NT length. METHODS This is a retrospective review of all adult trauma patients from 2003 to 2013 (age > 15 years) transported to a Level I trauma center. Patients underwent NT at the second intercostal space midclavicular line, either at the scene of injury, during transport (prehospital), or during initial hospital trauma resuscitation. Before March 2011, both prehospital and hospital trauma team NT equipment routinely had a 5-cm angiocatheter available. After March 2011, prehospital providers were provided an 8-cm angiocatheter. Effectiveness was defined as documented clinical improvement in respiratory, cardiovascular, or general clinical condition. RESULTS There were 91 NTs performed on 70 patients (21 bilateral placements) either in the field (prehospital, n = 41) or as part of resuscitation in the hospital (hospital, n = 29). Effectiveness of NT was 48% until March 2011 (n = 24). NT effectiveness was significantly higher in the prehospital setting than in the hospital (68.3% success rate vs. 20.7%, p < 0.01). Patients who underwent NT using 8 cm compared with 5 cm were significantly more effective (83% vs. 41%, respectively, p = 0.01). No complications of NT were identified in either group. CONCLUSION Eight-centimeter angiocatheters are more effective at chest decompression compared with currently recommended 5 cm at the second intercostal space midclavicular line. LEVEL OF EVIDENCE Therapeutic study, level IV.

Prehospital blood transfusion programs: Capabilities and lessons learned.

The Trauma and Hemostasis Oxygenation Research (THOR) network has met in Bergen, Norway every summer over the past six years in an effort to have experts in transfusion, blood banking, military medicine, and trauma surgery exchange ideas, share their experiences, and set an agenda to move the science of remote damage control resuscitation forward. In this manuscript, we supply the lessons shared from the authors/speakers to the reader. These lessons include the experiences of the Norwegian Military with freeze dried plasma and whole blood resuscitation, lessons from extreme remote damage control resuscitation situations on oceanic cruises, and remote blood product resuscitation techniques at Mayo Clinic and the University of Pittsburgh.

Comparison of Air and Ground Transport of Cardiac Patients

PURPOSE To investigate the outcome of cardiac patients transported by helicopter versus ground ambulance SETTING A hospital-based helicopter program in southeastern Minnesota METHODS Retrospective chart review assessing an 18-month period (January 1998 to June 1999). Charts were reviewed for type of cardiac diagnosis, level of pain, treatments en route, time to intervention, and length of stay (LOS). Two-hundred-sixty-six cardiac patients came by helicopter. Of the 86 turndowns, 50 came by ground ambulance; 28 records were recovered in this group. These patients composed the comparison ground group. RESULTS Prehospital time was less for patients transported by air than ground transports (P <.001). The amount of time from the call for transport until arrival at our hospital was less for helicopter transports (P =.002). Air transports had more patients with reduced chest pain on arrival. Difference in CCU LOS was not significant (P =.94). Air patients spent an average of 2 fewer days in the hospital than did ground patients (P =.036). DISCUSSION Helicopter transport benefits the cardiac patient with decreased chest pain as a result of more treatments en route; decreased time from the call until arrival, resulting in decreased time to intervention; and shorter prehospital time and hospital stays. CONCLUSION All of these improved variables relate to salvaged cardiac muscle.

How we provide thawed plasma for trauma patients

Almost 50% of trauma‐related fatalities within the first 24 hours of injury are related to hemorrhage. Improved survival in severely injured patients has been demonstrated when massive transfusion protocols are rapidly invoked as part of a therapeutic approach known as damage control resuscitation (DCR). DCR incorporates the early use of plasma to prevent or correct trauma‐induced coagulopathy. DCR often requires the transfusion of plasma before determination of the recipients ABO group. Historically, group AB plasma has been considered the “universal donor” plasma product. At our facility, the number of AB plasma products produced on an annual basis was found to be inadequate to support the trauma services DCR program. A joint decision was made by the transfusion medicine and trauma services to provide group A thawed plasma (TP) for in‐hospital and prehospital DCR protocols. A description of the implementation of group A TP into the DCR program is provided as well as outcome data pertaining to the use of TP in trauma patients.

The Airtraq Optical Laryngoscope in helicopter emergency medical services: a pilot trial.

OBJECTIVE To determine the degree of success helicopter emergency medical services personnel have in placing an endotracheal tube using a relatively new device for endotracheal intubation (ETI) known as the Airtraq (AT) Optical Laryngoscope (King Systems Corp, Noblesville, IN), and to determine the frequency with which flight crews had to resort to other means for advanced airway management. METHODS This prospective, observational pilot trial evaluated the critical care flight teams ability to perform ETI using the AT as a first-line device in the prehospital setting. Flight crews were instructed to use the AT for any patient needing ETI. Teams completed a 30-minute training session followed by mannequin practice. They documented situations and outcomes: reason for ETI, success in placing the AT, reason for unsuccessful placement, end-tidal carbon dioxide concentration in expired air (ETCO2), and where patients were when they underwent intubation (field, ambulance, aircraft, hospital). Data were abstracted and analyzed using JMP software version 7.0 (SAS Institute, Inc, Cary, NC). RESULTS Fifty cases involving use of the AT were analyzed. Median patient age was 51.5 years (range, 15-90; interquartile range, 36-64.5). Most patients were male (n = 37 [74%]). The primary reasons for intubation were unresponsiveness and altered loss of consciousness (n = 23 [46%]), respiratory distress or apnea (n = 8 [16%]), cardiac arrest (n = 10 [20%]), and combative behavior (n = 7 [14%]). AT was successful (n = 31[62%]) in 1 to 2 attempts. The primary reason for AT failure was blood or vomit in the airway (n = 8 [42.1%]); 48.1% (n = 25) of patients required a different management mode. CONCLUSIONS HEMS crews had difficulty placing successful ET tubes with this device after minimal education with a single regular-sized device. Difficulty was pronounced when blood or vomit was present and obstructing the optical view. Further study is needed to evaluate the implementation time, training time required, and possible design advantages of the AT compared with those of traditional emergent airway management techniques.

Prehospital Use of Blood and Plasma in Pediatric Trauma Patients

OBJECTIVE Our rural trauma center uses packed red blood cells (PRBCs) and plasma onboard our helicopter to offset the delay of transport. We summarize our initial experience with prehospital blood use in pediatric trauma patients. METHODS Our air ambulance service began carrying PRBCs in 1987 and plasma in 2009. We performed a 9-year retrospective review including patients (< 18 years) who received blood during helicopter transports. Only patients transported to our level 1 trauma center were included to ensure complete follow-up. RESULTS Sixteen patients (6 females) were identified with a mean age of 13 years. The mean transport time was 30 minutes with 75% transferred in from a referring center. Injuries were blunt in 9 patients and penetrating in 2 patients. The mean Injury Severity Score was 30. Fifteen patients received an average of 1.5 units of PRBCs during flight. Indications for PRBCs were severe anemia (6), known blood loss (5), and nonresponder to intravenous fluids (4). Average hemoglobin improved from 9.4 to 11.4 mg/dL at our center. Base deficit improved from -7 to -5.7 at arrival. Five patients received a mean of 1.4 units of plasma. The arrival international normalized ratio was 1.4. The average length of stay was 9.3 days. Four patients died. Trauma Related Injury Severity Score showed 3 patients were unexpected survivors (0.24, 0.24, and 0.38). CONCLUSION Prehospital use of blood in injured children is rare. However, when indicated, this initial review of our protocol showed increased hemoglobin, decreased acidosis, and unexpected survivors with our program. Because of the rarity of prehospital blood use in children, administration triggers require continued review and refinement.