Simon Glasgow

Blood and bombs: the demand and use of blood following the London Bombings of 7 July 2005 – a retrospective review

Mass casualty events (MCE) present health systems with a sudden demand on key services. The overall objective of this study was to describe the experience of the National Blood Service (NBS) following the largest UK MCE in recent times. Data was collated from the NBS database and directly from the hospitals involved. All data was collected immediately following the event and included: all blood components requested, issued and transfused in relation to the bombings, blood stock levels at the time and the injury profiles of the casualties transfused. The total NBS order from hospitals for the event was 1455 units of blood components. All requests were fulfilled, this included: 978 units of red cells (RC), 36 doses of platelets, 141 units of fresh frozen plasma (FFP) and 300 doses of cryoprecipitate. The amount of blood ordered was three times that initially used and the total number of RC transfused in treating all victims from admission to discharge was approximately 440 units. The greatest use of blood components was for those casualties who had sustained traumatic amputations amongst their injury profile. Published data with which to compare these results is lacking, although the RC use was similar to the initial mean individual usage described in previous military and civilian bombings. The overall implication for any blood service remains, there is now likely to be a far greater demand for plasma, platelets and cryoprecipitate in any future incidents involving victims suffering major haemorrhage.

Meta-analysis of prognostic factors for amputation following surgical repair of lower extremity vascular trauma

Lower extremity vascular trauma (LEVT) is a major cause of amputation. A clear understanding of prognostic factors for amputation is important to inform surgical decision‐making, patient counselling and risk stratification. The aim was to develop an understanding of prognostic factors for amputation following surgical repair of LEVT.

Trauma-induced secondary cardiac injury is associated with hyperacute elevations in inflammatory cytokines.

Introduction Clinical evidence supports the existence of a trauma-induced secondary cardiac injury. Experimental research suggests inflammation as a possible mechanism. The study aimed to determine if there was an early association between inflammation and secondary cardiac injury in trauma patients. Methods A cohort study of critically injured patients between January 2008 and January 2010 was undertaken. Levels of the cardiac biomarkers troponin I and heart-specific fatty acid–binding protein and the cytokines tumor necrosis factor &agr; (TNF-&agr;), interleukin (IL)-6, IL-1&bgr;, and IL-8 were measured on admission to hospital, and again at 24 and 72 h. Participants were reviewed for adverse cardiac events (ACEs) and in-hospital mortality. Results Of 135 patients recruited, 18 (13%) had an ACE. Patients with ACEs had higher admission plasma levels of TNF-&agr; (5.4 vs. 3.8 pg/mL; P = 0.03), IL-6 (140 vs. 58.9 pg/mL, P = 0.009), and IL-8 (19.3 vs. 9.1 pg/mL, P = 0.03) compared with those without events. Hour 24 cytokines were not associated with events, but IL-8 (14.5 vs. 5.8 pg/mL; P = 0.01) and IL-1&bgr; (0.55 vs. 0.19 pg/mL; P = 0.04) were higher in patients with ACEs at 72 hours. Admission IL-6 was independently associated with heart-specific fatty acid–binding protein increase (P < 0.05). Patients who presented with an elevated troponin I combined with either an elevated TNF-&agr; (relative risk [RR], 11.0; 95% confidence interval [CI], 1.8–66.9; P = 0.015), elevated IL-6 (RR, 17.3; 95% CI, 2.9–101.4; P = 0.001), or elevated IL-8 (RR, 15.0; 95% CI, 3.1–72.9; P = 0.008) were at the highest risk of in-hospital death when compared with individuals with normal biomarker and cytokine values. Conclusions There is an association between hyperacute elevations in inflammatory cytokines with cardiac injury and ACEs in critically injured patients. Biomarker evidence of cardiac injury and inflammation on admission is associated with a higher risk of in-hospital death.

Mass casualty events: blood transfusion emergency preparedness across the continuum of care.

Transfusion support is a key enabler to the response to mass casualty events (MCEs). Transfusion demand and capability planning should be an integrated part of the medical planning process for emergency system preparedness. Historical reviews have recently supported demand planning for MCEs and mass gatherings; however, computer modeling offers greater insights for resource management. The challenge remains balancing demand and supply especially the demand for universal components such as group O red blood cells. The current prehospital and hospital capability has benefited from investment in the management of massive hemorrhage. The management of massive hemorrhage should address both hemorrhage control and hemostatic support. Labile blood components cannot be stockpiled and a large surge in demand is a challenge for transfusion providers. The use of blood components may need to be triaged and demand managed. Two contrasting models of transfusion planning for MCEs are described. Both illustrate an integrated approach to preparedness where blood transfusion services work closely with health care providers and the donor community. Preparedness includes appropriate stock management and resupply from other centers. However, the introduction of alternative transfusion products, transfusion triage, and the greater use of an emergency donor panel to provide whole blood may permit greater resilience.

Going for gold: blood planning for the London 2012 Olympic Games

The Olympics is one of the largest sporting events in the world. Major events may be complicated by disruption of normal activity and major incidents. Health care and transfusion planners should be prepared for both. Previously, transfusion contingency planning has focused on seasonal blood shortages and pandemic influenzas. This article is the first published account of transfusion contingency planning for a major event. We describe the issues encountered and the lessons identified during transfusion planning for the London 2012 Olympics.

A comprehensive review of blood product use in civilian mass casualty events.

I recent decades, there has been a significant increase in the frequency of disasters and major emergencies. By definition, these mass casualty events (MCEs) result in large numbers of severely injured patients, which overwhelm available resources, thereby limiting the ability to deliver optimal care. In these casualties, hemorrhage is a leading cause of preventable mortality, accounting for almost 50% of deaths in the first 24 hours. Modern transfusion strategies recommend high ratios of blood components, such as fresh frozen plasma (FFP) to red blood cells (RBCs) from the outset as part of damage-control resuscitation (DCR). The timely availability and appropriate delivery of blood products in MCEs is essential to improve critical mortality in severely injured patients. Emergency preparedness for future MCEs must therefore include evidence-based transfusion strategies and blood bank planning. Predicting blood product requirements for MCEs is challenging. Previous studies of events, in both military and civilian settings, have been based on single-center experiences and quantified RBC requirements by units used per victim or per hospitalized patient. In civilian and military trauma, casualty blood requirements depend on factors such as injury severity and mechanism of injury (MOI). Some of this information may not be applicable or readily available in MCEs. Past experience of blood use in MCEs has indicated that held stocks of RBCs have been adequate for a hospitals’ capacity to deliver them to patients. Despite this, there are continued reports of emergency donation following MCEs suggesting stock availability in blood banks and demand requires further investigation. In conjunction with this, transfusion strategies in trauma have evolved in recent years with the advent of DCR using early high-dose coagulation therapy alongside RBCs to prevent and treat coagulopathy. This new approach has not been explored fully in the context of MCEs and the potential impact it may have on supply and demand during these events. The overall objective of this article was to determine if blood requirements necessary to adequately manage a civilian MCE are predictable based on historical data and events. The first aim of the study was to perform a review of the adequacy of reporting of blood product use across a full range of civilian MCEs. Second, we wished to determine whether a predictive relationship exists between blood use and available casualty profiles. The third aim was to determine whether any existing relationship is affected by the nature of the event itself. Finally, we wished to investigate the potential effect that current trauma transfusion practices would have had on blood demands during previous events. We conducted a comprehensive review of literature from 1911 to 2011 and compared findings with civilian blood use data from a major trauma center.

Managing the surge in demand for blood following mass casualty events: Early automatic restocking may preserve red cell supply.

BACKGROUND Traumatic hemorrhage is a leading preventable cause of mortality following mass casualty events (MCEs). Improving outcomes requires adequate in-hospital provision of high-volume red blood cell (RBC) transfusions. This study investigated strategies for optimizing RBC provision to casualties in MCEs using simulation modeling. METHODS A computerized simulation model of a UK major trauma center (TC) transfusion system was developed. The model used input data from past MCEs and civilian and military trauma registries. We simulated the effect of varying on-shelf RBC stock hold and the timing of externally restocking RBC supplies on TC treatment capacity across increasing loads of priority one (P1) and two (P2) casualties from an event. RESULTS Thirty-five thousand simulations were performed. A casualty load of 20 P1s and P2s under standard TC RBC stock conditions left 35% (95% confidence interval, 32–38%) of P1s and 7% (4–10%) of P2s inadequately treated for hemorrhage. Additionally, exhaustion of type O emergency RBC stocks (a surrogate for reaching surge capacity) occurred in a median of 10 hours (IQR, 5 to >12 hours). Doubling casualty load increased this to 60% (57–63%) and 30% (26–34%), respectively, with capacity reached in 2 hours (1–3 hours). The model identified a minimum requirement of 12 U of on-shelf RBCs per P1/P2 casualty received to prevent surge capacity being reached. Restocking supplies in an MCE versus greater permanent on-shelf RBC stock holds was considered at increasing hourly intervals. T-test analysis showed no difference between stock hold versus supply restocking with regard to overall outcomes for MCEs up to 80 P1s and P2s in size (p < 0.05), provided the restock occurred within 6 hours. CONCLUSION Even limited-sized MCEs threaten to overwhelm TC transfusion systems. An early-automated push approach to restocking RBCs initiated by central suppliers can produce equivocal outcomes compared with holding excess stock permanently at TCs. LEVEL OF EVIDENCE Therapeutic/care management study, level IV.

Mild, moderate or severe lung injury after trauma: what are the early predictors?

Background Lung injury is a common complication following major trauma. Large volume transfusions, thoracic injury, pulmonary contusion, and hypo perfusion have previously been associated with its development [1]. However, early predictors of differing grades of lung injury following trauma are yet to be described. The objective of this study was to characterise the admission risk factors associated with differing severity of lung injury in trauma patients.