Update on pre-hospital blood transfusions Dr Anne Weaver Consultant in Emergency Medicine & Pre-hospital Care RDCR 2016
ObjecGves How and why Blood on board was launched Share our results Next steps
And will congnue your efforts
UK stats trauma haemorrhage 4700 / yr major haemorrhage (1550 dead) 1300 / yr massive haemorrhage (585 dead) Deaths 50% in 24hrs (50% in first 4 hrs) 50% needed urgent surgery 85 million / yr
Vicky
Video / imaginagon Look Colour Limb posigon Eyes no drugs Why is she dying? What intervengons does she need? What fluid would you give her?
Crystalloid Every UK ambulance Cheap safe Useful for most pts but they are not bleeding How much will Vicky need to resuscitate her?
Why would you give her crystalloid? Doesn t stay in vascular space 3 Gmes volume for effect No oxygen carrying capacity Increases Gssue oedema Increases acidosis Old debate. Over it! Only if you have no other opgon..
Vicky needs Team to idengfy shock Make a diagnosis Deliver excellent basic care Provide appropriate advanced intervengons Make a risk-benefit analysis about whether to give blood
Catastrophic haemorrhage in PHC C ABC Tourniquets Novel haemostagc agents - celox Handling and packaging Splintage Permissive hypotension Damage control resuscitagon
Catastrophic haemorrhage in PHC RecogniGon of serious haemorrhage AcGvate massive haemorrhage protocols Pre-hospital transfusion Emergency reversal of warfarin at scene / en route Awareness of novel oral ang-coagulants Aggressive vascular control in the field
Vicky needs a fluid that Carries oxygen to repay oxygen debt Contributes to haemostagc resuscitagon Stays in the intravascular space There are risks with blood transfusion but her predicted mortality exceeds 50%
2007 - how did it all start? Serious incidents at RLH Interested group of people Development of Code Red protocol Increasing frustragon / awareness of potengal to do more Watching pagents die
Pelvic injury
Time to definigve care..
CODE RED @ RLH 2008
1:1
CODE RED PROTOCOL Pre-alert from HEMS team Average age 34 yrs Mortality 49% Replicated across other London MTCs
2011 TXA for Code Red only
March 2012 Blood on Board
Equipment
SOP indicagons for PH transfusion CODE RED in extremis or TraumaGc arrest where hypovolaemia is considered to be a contribugng factor (Compensatory Reserve Index = RED?)
>1000 missions 50 prehospital transfusions 28 Code Red in extremis 22 trauma;c cardiac arrests 11 PLE on scene 10 ROSC 1 infant in arrest to ED
39 PH Txn to ED 24 survived 8 died in ED 3 died in OR 4 died on ICU
Mean age 35yrs 80% male 45% ROSC from TCA
2.8 units PRBC transfused On-scene ;me 37 mins Hb 14.0 ph 7.07 BE 12.8
First 6 months data 10.5u PRBC in 24hrs 8.3u FFP in 24 hrs 141 units PRBC transfused onscene 100% traceability 1 unit PRBC wasted
18 months data
Our results Feasible pracgce and low waste Associated with increased survival to ED PotenGal improved organ donagon rates Will not demonstrate lactate clearance or increased survival to discharge Not a trial powered to prove anything Needed blood product pre-hospital support our advanced pracgce Replicate hospital care
Pre-hospital blood trials PRBC Improved outcomes not always stat sig 6hr survival 24hr survival Reduced blood product transfusion in 24hrs Improved BE / acid base balance on admission Feasible Low waste
InnovaGon has a nagonal impact AssociaGon of Air Ambulances UK HEMS Kent, Surrey and Sussex Air Ambulance Thames Valley AA EMRS Scotland GNAAS - Tyneside GWAAS / Wiltshire Welsh EMRT
Next steps for LAA blood project Enhanced safety / logisgcs tracking systems / data collecgon AddiGonal product availability for HEMS Whole blood, liquid plasma, fibrinogen Thawed plasma in resus at RLH Improve in-hospital processes Mass casualty planning
Vicky
ROYAL LONDON HOSPITAL MTC CODE RED MORTALITY