BLOOD IN THE AIR: THE STARS EXPERIENCE Dr. Ryan Deedo MD DipAeroRT FRCPC Transport Physician STARS Medical Communications Lead (Calgary)

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1 BLOOD IN THE AIR: THE STARS EXPERIENCE Dr. Ryan Deedo MD DipAeroRT FRCPC Transport Physician STARS Medical Communications Lead (Calgary)

2 What s new at STARS?

3 STARS bases and response areas

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5 Operations / Patient / Air Crew / Medical Crew

6 WHY BLOOD?

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9 What did STARS do in Alberta in 2013: Calgary Edmonton Grande Prairie Total Scene patient missions (total) IFT patient missions (total) Adult trauma Adult medical Ped trauma Ped medical NICU High risk OBS Patients

10 Chance to affect large number critical patients

11 STARS BLOOD INITIATIVE Program Objectives: To have 2 units of prbcs available on aircraft 24/7 Download item for PICU/NICU trips, otherwise will be available on all other missions To safely store, transport, and return unused prbc units to the blood bank with minimal/no waste To only transfuse patients that meet criteria for blood transfusion

12 BLOOD TRANSFUSION CRITERIA Blood transfusion should never be a substitute for meticulous attention to hemorrhage control. 1. Hemoglobin less than or equal to 70 g/l in any transported patient that is symptomatic from their anemia (not for asymptomatic patients). 2. Hemoglobin less than 80 g/l with ischemic heart disease or other cardiac compromise and symptomatic. 3. If EBL (estimated blood loss) greater than 20% body total 4. Hemoglobin less than 90 g/l and ongoing significant losses anticipated (that can t be readily stopped, eg. massive GI bleeding, retroperitoneal hemorrhage, intra-thoracic hemorrhage, or intra-abdominal hemorrhage). 5. Pre-hospital: Persistent hemorrhagic shock despite hemorrhage control measures after crystalloid infusion (maximum 2 litres). a. Hemorrhagic shock defined as persistent tachycardia despite analgesia, hemorrhage control, and a trial of crystalloid fluids; or hypotension (SBP < 100 mm Hg) despite hemorrhage control and a crystalloid trial. 6. Inter-facility: Persistent hemorrhagic shock where there is limited or no access to cross-matched blood and ongoing requirement for transfusion. a. Hemorrhagic shock as defined in point 5

13 TRANSFUSION PROTOCOL Blood transfusion may not be started by the air medical crew without first contacting the transport physician on call. The blood cooler seal is not to be broken until the transport physician has agreed that transfusion is warranted. If the air medical crew is not able to contact their transport physician the ELC will attempt to contact another transport physician on call for advice. If no physician can be contacted than blood transfusion may not be started by the air medical crew.

14 TRANSFUSION PROTOCOL Once the decision to transfuse has been made, the patient should receive both units (if possible) if an adult If both units not given en route then consider spiking the remaining unit and starting it before handing over the patient (if appropriate) If the patient is a child they should receive appropriate boluses of blood products with reassessment in between (20-40 cc/kg bolus dosing)

15 DECISION TO TRANSFUSE

16 BLOOD CHECKS

17 KEEP IT WARM enflow IV warmer

18 Diagnosis Age/Sex STARS Blood Products Patient ABO/Rh Status RC Trauma ruptured aortic 37 year old male 2 5 RC Survived arch MBC poly-trauma 41 year old male 2 8RC Survived Poly-trauma 55 year old female 2 2RC, 1500 IU PCC A positive Survived Traumatic crush injury 61 year old male 2 3RC Deceased 1 day Poly-trauma 46 year old female 2 21RC, 8FFP, 3 platelet, 10 cryo A negative switched to Rh pos at hospital Survived GI Bleed 53 year old male 2 8RC, 14FFP, 4 O positive Deceased 2 days platelet Trauma 12 year old female 1 9RC, 15FFP, 1 A positive Survived platelet, 4 cryo GSW 55 year old male 2 9RC A positive Survived GSW Unknown male 1 Deceased at scene Wegener s 62 year old male 2 11RC, 8FFP, 8 platelet 4 L AFFP apheresis MVC 49 year old female 2 12RC, 5 FFP, 2 platelet, 10 cryo Polytrauma 15 year old male 2 10RC, 4FFP, 2 platelet B positive A positive O positive Deceased 2 days Deceased 1 day Deceased same day

19 Brown JB, et al., Pre-Trauma Center Red Blood Cell Transfusion Is Associated with Improved Early Outcomes in Air Medical Trauma Patients, Journal of the American College of Surgeons (2015), doi: / j.jamcollsurg (in-press) Conclusions: PTC RBC was associated with an increased probability of 24-hour survival, decreased risk of shock, and lower 24-hour RBC requirement. PTC RBC appears beneficial in severely injured air medical trauma patients and prospective study is warranted as PTC RBC transfusion becomes more readily available.

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22 BLOOD IN THE AIR? So far so good! No adverse events to date On review all cases appropriate per MD review No wasted units to date

23 Questions?

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