VISITAS RECIENTES

AUTISMO TEA PDF

AUTISMO TEA PDF
TRASTORNO ESPECTRO AUTISMO y URGENCIAS PDF

We Support The Free Share of the Medical Information

Enlaces PDF por Temas

Nota Importante

Aunque pueda contener afirmaciones, datos o apuntes procedentes de instituciones o profesionales sanitarios, la información contenida en el blog EMS Solutions International está editada y elaborada por profesionales de la salud. Recomendamos al lector que cualquier duda relacionada con la salud sea consultada con un profesional del ámbito sanitario. by Dr. Ramon REYES, MD

Niveles de Alerta Antiterrorista en España. Nivel Actual 4 de 5.

Niveles de Alerta Antiterrorista en España. Nivel Actual 4 de 5.
Fuente Ministerio de Interior de España
Mostrando entradas con la etiqueta BLOOD. Mostrar todas las entradas
Mostrando entradas con la etiqueta BLOOD. Mostrar todas las entradas

viernes, 8 de septiembre de 2023

ACS TQIP Massive Transfusion in Trauma Guidelines pdf by American College of Surgeon

 

ACS TQIP Massive Transfusion in Trauma Guidelines pdf by American College of Surgeon 

Por favor comparte nuestras redes 

Grupo Biblioteca/PDFs gratis en Facebook

Facebook




Pinterest

Twitter

Blog

Gracias a todos el Canal somos mas de  1000 participantes en WhatsApp. Recordar este es un canal y sirve de enlace para entrar a los tres grupos; TACMED, TRAUMA y Científico. ahí es que se puede interactuar y publicar. Si le molestan las notificaciones, solo tiene que silenciarlas y así se beneficia de la informacion y la puede revisar cuando usted así lo disponga sin el molestoso sonido de dichas actualizaciones, Gracias a todos Dr. Ramon Reyes, MD Enlace al 




Enlace a Científico https://chat.whatsapp.com/IK9fNJbihS7AT6O4YMc3Vw en WhatsApp 

TELEGRAM Emergencias https://t.me/+sF_-DycbQfI0YzJk  

TELEGRAM TACMED https://t.me/CIAMTO
Download directly from ACS HERE

viernes, 23 de marzo de 2018

Three Reasons Not to Use Normal Saline or Crystalloids in Trauma Wed, Mar 14, 2018 By Brandon M. Carius, MPAS, PA-C , Andrew D. Fisher, MPAS, PA-C [C]

Todos Nuestros VIDEOS en YouTube https://www.youtube.com/c/RamonReyes2015 
Grupo en TELEGRAM Sociedad Iberoamericana de Emergencias https://t.me/joinchat/FpTSAEHYjNLkNbq9204IzA

You're responding to a gunshot wound. When you arrive, you find a young man has been shot in the chest, and has significant hemorrhage. As you load him into the ambulance, your partner tells you he is spiking a 1-liter bag of 0.9% sodium chloride, also known as normal saline (NS). 
You're curious, because the patient is hemorrhaging blood, not salt water, and ask why you’re not prepping blood products instead.
Your partner responds, “Because it’s something we can give him now, and it helps with circulation.”
But, does it actually help?
This review provides historical information and research with the aim of making a case against the use of NS, and why the word “normal” may be a misnomer. This can be applied to all crystalloids or clear fluid with regard to trauma resuscitation.
The goal of this article is to illustrate the many deficiencies of administering NS in a trauma patient, and to encourage critical thinking regarding current fluid resuscitation strategies that discuss increasing support for the use of blood components, including whole blood (WB).

History of Crystalloids

NS has existed in some form for nearly 200 years, largely tracing its roots back to the European cholera pandemic of 1831.1 But the solutions that were used in this outbreak, and for several decades of medicine thereafter, bear little resemblance to the modern mixture we use, both in content and in appropriate use.2
The first recorded experiment in modern IV fluid therapy is believed to be from a Russian chemist who, in treating a severely ill cholera patient, “injected 6 oz. (180 mL) of water intravenously.”1
William Brooke O’Shaughnessy, a recent medical school graduate, later published a paper in the Lancet in December 1831, stating that the goals of IV fluid in treating cholera were, “First, to restore the blood to its natural specific gravity; Second, to restore its deficient saline matters … these can only be effected … by injection of aqueous fluid into the veins.”Thus, we see the early foundations of saline, although referring to it as “normal” wouldn't occur until many years later.
In the 1830s, there were numerous practitioners experimenting with various solutions in an attempt to “restore the natural current in the veins and arteries” and “improve the colour of the blood.”4
In May 1832, Robert Lewins described treatments used by Thomas Latta on six patients, with solutions consisting of “two drachms of muriate, and two scruples of carbonate, of soda, to 60 ounces of water.”4 When Dr. Latta later wrote of these experiments himself, he noted a different composition of his makeshift IV fluid than was previously described.1
Other concoctions of the time included “one drachm muriate of soda, 10 grains carbonate of soda in two pounds aqua calid.”4 Historical reviews have noted that some of these compositions actually had no detailed measurements recorded at all.
As the cholera pandemic waned in 1833, there was less urgency for IV fluid research, and for many years following, IV fluid research and publication were rare.
The first time the term “normal saline” appears in literature came decades later in the Sept. 29, 1888, edition of the Lancet.1 A patient who had “suffered over a month of vomiting, with minimal oral intake. .. [was] ... injected with 34 fluid oz. [approximately 1020 mL]” of a fluid by Churton,5 which, as shown in Table 1, bears little resemblance to the NS used today (or, with phosphate and bicarbonate, bears little resemblance to any crystalloid used today).
Table 1: Comparison of Churton's solution with normal saline
SolutionNa+ (mmol/L)Cl- (mmol/L)POPO42- (mmol/L)HCO3- (mmol/L)
Churton's solution11501282.527
Normal saline15415400
Other isolated case reports described similar situations, but again, these IV fluid treatments weren't consistent with a 0.9% sodium chloride composition. Therefore, authors have speculated that word-of-mouth was likely to blame, rather than actual scientific research and publication.1
The NS term did find scientific support, however, after Dutch chemist Hartog Jakob Hamburger, concluded that “the blood of the majority of warm-blooded animals, including man, was isotonic with a sodium chloride solution of 0.9%,”6 effectively linking the two. As it's been described, “the scientific evidence supporting the use of 0.9% saline in clinical practice seems to be based solely on this … [otherwise] it remains a mystery how it came into general use as an IV fluid.”1
The use of NS and other crystalloids would have been used as the primary prehospital resuscitation fluid of choice for the past 30 years. However, “the historic role of crystalloid and colloid solutions in trauma resuscitation represents the triumph of hope and wishful thinking over physiology and experience.”7
Now, with this checkered background of the solution we call NS today, we present reasons why NS shouldn't be a mainstay of trauma treatment.

1. Normal saline isn't blood.

This is obvious, but it's an important introductory point. NS, as well as similar fluids like Lactated Ringers (LR), are crystalloids, and therefore consist of an electrolyte solute (in this case, sodium and chloride) suspended in a water solvent. As previously mentioned, NS solution has never truly proven itself worthy of the “normal” or “physiological” titles that it bears today.2
There are substantial disparities between the normality of human serum and NS. The comparison of NS and normal serum electrolyte ranges are listed in Table 2.
Table 2: Normal saline vs. normal serum electrolyte ranges
SolutionNa+ (mmol/L)Cl- (mmol/L)K+ (mmol/L)Ca2+ (mg/dL)Mg2+ (mg/dL)
Normal serum134-14598-1073.6-5.28.9-10.11.7-2.3
Normal saline154154000
Prior literature has described hemorrhagic shock as a type of “blood failure.”8,9 The goals of trauma resuscitation are to restore the functionality of blood, this is completed by restoring:10
  • Circulating volume;
  • Oxygen delivery; and
  • Hemostatic potential.
NS addresses none of these critical tasks.
Prior literature has argued that NS can increase circulating volume, and that adding salt water in trauma patients will help “circulate” remaining RBCs to deliver oxygen.11 However, NS itself doesn't serve this function. It's important to acknowledge this basic, yet critical, issue, as well as its increased risk of mortality in hemorrhagic patients.12 
Similarly, issues with significant extravasation that negate increasing fluid loads undermine any argument to use NS as temporary volume booster.
Simply adding fluids to a hemorrhaging body in order to theoretically “push” existing RBCs around for oxygen delivery and waste removal is largely unsupported in modern trauma literature, and, according to some, there's no human data supporting the claim that a large volume crystalloid resuscitation strategy will actually improve organ perfusion.13
Conversely, this strategy can lead to significant complications, including compartment syndrome, dilutional coagulopathy, hyperchloremic metabolic acidosis, immune dysfunction, and kidney injury.14-16
Other factors to consider include the oxygen debt and deficit that are accumulated in hemorrhagic shock. In a normal healthy body, oxygen consumption (VO2) is independent of cardiac output and therefore oxygen delivery (DO2). In hemorrhagic shock, oxygen deficit occurs when the amount of oxygen demanded by the tissues is inadequately matched by supply. Over time, these multiple deficits, result in an oxygen debt. The seriousness of an oxygen debt can't be overstated; it's the “only physiological variable that can quantitatively predict survival.”17
Crystalloids, like NS, cannot adequately repay oxygen debt in a timely manner.

2. Normal saline worsens acidosis & coagulopathy.

Most prehospital medical providers are well-versed on the three main concerns of significant hemorrhage, also known as the “lethal triad,” metabolic acidosis, coagulopathy and hypothermia. The use of NS in trauma resuscitation has been shown to exacerbate the first two aspects of this triad, metabolic acidosis and coagulopathy, as well as effect blood concentration and induce blood vessel dilation, all of which have the potential to worsen patient outcomes.18
It’s important to stress the predisposition for metabolic acidosis in trauma patients, as poorly perfused regions of tissue accumulate lactic acid and other cellular wastes, thus decreasing blood pH. Although trauma patients are already prone to acidosis, resuscitation attempts with supraphysiological chloride content in NS have been shown to worsen the patient’s condition by furthering hyperchloremic metabolic acidosis.15,18,19
The risk of NS-induced acidosis has been well-documented. One of the early reports comes from the journal Anesthesiology, where a 1997 case noted that a patient primarily received NS during the course of a long kidney surgery.20 The timeline and results progressed as follows:
  • After 4 hours, the patient was estimated to have lost 1L of blood, and had received 5L NS with 1L albumin and 2 units of packed RBCs. The pH at that time was 7.28 (normal = 7.35-7.45), demonstrating an acidotic state.
  • Sodium bicarbonate was then administered, and the pH rose to 7.32.
  • After 8 hours, blood loss was estimated to have been 3.5L total, and the patient was noted to have received 20L of NS, with 9 units of packed RBCs and minimal other products. The pH at that point had fallen to 7.16, signaling onset of significant acidosis.
As the authors note, “the metabolic acidosis was diagnosed as a dilutional nonunion gap hyperchloremic metabolic acidosis resulting from the large volume of normal saline given during surgery and not from inadequate end organ perfusion.”20
Numerous studies have investigated the effects of NS in healthy volunteers, finding increased chloride levels and decreases in both bicarbonate and pH, thereby demonstrating the acidotic effect NS has on a healthy non-traumatized body.21,22
As this effect happens in healthy individuals, the effect in a trauma patient, already at risk for metabolic acidosis, creates an increased concern for worsened outcomes. Hemorrhaged animal models have demonstrated significant hyperchloremic acidosis from NS administration.23,24 This concern has been further validated by real-world findings of increased mortality in trauma patients when NS is used for resuscitation,13 including one large-scale study involving more than 3,000 trauma patients which demonstrated worsened outcomes when NS was used for fluid resuscitation.12
Why are there worsened outcomes with NS? What does metabolic acidosis, exacerbated by NS administration, do to the lethal triad in trauma patients? 
NS-induced acidosis has been shown to directly decrease cardiac contractility and chronicity, as well as decrease the effectiveness of circulating catecholamines such as epinephrine,16,23 which can then further decrease cardiovascular function.
Furthermore, acidotic states have been demonstrated in animal models to significantly decrease fibrinogen concentration and impair thrombin generation,23,24 showing a downstream effect on other systems that are critical to stabilizing traumatic hemorrhage. Thus, many have concluded that based on NS-associated acidosis alone, the use of NS for trauma resuscitation is not supported.21
In severe trauma, effective coagulation is vital to help prevent further blood and fluid loss. Physiologically, as a crystalloid, NS likely contributes to what has been best described as trauma induced coagulopathy (TIC).9
There are two arms of trauma induced coagulopathy, acute traumatic coagulopathy (ATC) and iatrogenic coagulopathy. Overall, ATC is similar to TIC, with the significant difference being it occurs within the first 30 minutes of injury. Iatrogenic coagulopathy is the initiation or furthering of these issues through the (largely) use of improper fluid resuscitation strategies in hemorrhagic patients.
Directly, NS is linked to iatrogenic coagulopathy via the functional impairment of thrombin and fibrin, which are essential to clot formation.25 Indirectly, as mentioned above, the use of NS for resuscitation can potentiate iatrogenic coagulopathy via increased acidosis and inflammatory markers.16,23,24,26 Beyond concerns for preexisting ATC in patients with hemorrhage, a rush to administer NS likely serves to induce iatrogenic coagulopathy and thus further prevent effective coagulation.
NS contains no clotting factors or clotting support, and in fact, as it further dilutes coagulation factors and increases blood acidity, NS can significantly degrade the body’s ability to clot and achieve hemostasis.8,9Coagulopathy complications are furthered by rampant NS bolus administration in attempts to maintain or normalize BP, which could literally blast apart, or otherwise disrupt, previously clotted vessels.18 
Not only does NS directly and indirectly impair new clot formation, it also has the potential to significantly disrupt and destroy existing clots. Though “lower blood pressure enhances regional vasoconstriction and facilitates clot formation and stabilization,” a patient receiving a bolus NS does the exact opposite: it uses salt water to keep vessels open and further prevents adequate clotting in areas of trauma.

3. Hemodilution & vascular changes.

As mentioned previously, a primary goal of trauma resuscitation is to achieve a stable blood pressure, and NS-led resuscitation is partially supported by the argument that it “keeps the blood circulating” for continued organ perfusion. Therefore, many protocols utilize an NS bolus of 1-2 L in an attempt to normalize SBP or MAP, as well as the quintessential 3:1 IV fluid-to-blood lost ratio that we commonly find in trauma literature.27
Although studies have proven that administration of any crystalloid fluids can have significant vasodilatory effects, this effect is greatest with NS.22,24 Research has further revealed that only 20% of infused volume remains intravascular, demonstrating a substantial loss, and waste, of administered fluid.27
NS-induced vasodilation and leakage will cause further cardiovascular stress (in addition to the metabolic acidosis-induced stress mentioned above) in order to further maintain circulatory support. Ironically, NS administration dilates and causes leakage in the very vessels it's meant to maintain, therefore producing greater stress on the systems it was given to support.
Additionally, NS has significant effects on another critical organ that's already under stress in a trauma patient: the kidneys—an important clearinghouse for metabolic wastes (including excess sodium and chloride, among others), as well as regulation of acid-base balance. 
Although we referenced the vasodilation effects above, studies have established significant reductions in renal blood flow and tissue perfusion with NS administration,19 thereby harming a critical organ that helps regulate one of the very imbalances that NS creates. The "yin-yang" effect of renal vasoconstriction and vasodilation elsewhere may help explain why crystalloid administration has been determined to be an independent mortality risk factor when used in an attempt to normalize blood pressure (BP) in trauma patients that are given as little as 1.5L of NS.12
Further damage is done in the lungs, where crystalloids have been found as a modifiable risk factor in trauma and resuscitation.28

Conclusion

To summarize, the suboptimal characteristics and harmful effects of NS in trauma resuscitation include the following:
  • Its inception history is vague;
  • It was never initially intended for use in trauma;
  • It’s not blood;
  • It doesn’t mimic blood well; and
  • It can actually cause significant harm and exacerbate ongoing pathology in a trauma patient, worsening their condition.
Given this, why would you administer NS in the setting of traumatic hemorrhage?
Supported by this review, it's important to reiterate and acknowledge that “the historic role of crystalloid and colloid solutions in trauma resuscitation represents the triumph of hope and wishful thinking over physiology and experience,”7 and therefore we strongly agree that “crystalloid administration should be reduced or eliminated once blood products are available.”29

Disclaimer: The views expressed in this article are those of the authors and do not reflect the official policy or position of the US Army Medical Department, the US Army Office of the Surgeon General, the Department of the Army, Department of Defense, or the US Government.

References

1. Awad S, Allison SP, Lobo DN. The history of 0.9% saline. Clin Nutr. 2008;27(2):179–188.
2. Chen L. The myth of 0.9% saline: Neither normal nor physiological. Crit Care Nurs Q. 2015;38(4):385–389.
3. O’Shaughnessy WB. Experiments on the blood in cholera. Lancet. 1831;17(35):490.
4. Lewins R. Injection of saline solutions in extraordinary quantities into the veins of malignant cholera. Lancet. 1832;18(456):243–244.
5. Churton DR. Leeds general infirmary: A case of scirrhus of the pylorus, with excessive vomiting; repeated intravenous injections of saline solution; remarks. Lancet. 1888;132(3396):620–621.
6. Hamburger HJ. A Discourse on permeability in physiology and pathology. Lancet. 1921;198(5125):1039–1045.
7. Cap AP, Pidcoke HF, DePasquale M, et al. Blood far forward: Time to get moving! J Trauma Acute Care Surg. 2015;78(6 Suppl 1):S2–6.
8. White NJ, Ward KR, Pati S, et al. Hemorrhagic blood failure: Oxygen debt, coagulopathy, and endothelial damage. J Trauma Acute Care Surg. 2017;82(6S Suppl 1):S41–S49.
9. Meledeo MA, Herzig MC, Bynum JA, et al. Acute traumatic coagulopathy: The elephant in a room of blind scientists. J Trauma Acute Care Surg. 2017;82(6S Suppl 1):S33–S40.
10. Cap AP. Whole blood (functionality): The cornerstone of remote damage control resuscitation. Oral presentation at Special Operations Medical Association Scientific Symposium; May 2017; Charlotte, NC.
11. Lilly MP, Gala GJ, Carlson DE, et al. Saline resuscitation after fixed-volume hemorrhage. Role of resuscitation volume and rate of infusion. Ann Surg. 1992;216(2):161–171.
12. Ley EJ, Clond MA, Srour MK, et al. Emergency department crystalloid resuscitation of 1.5 L or more is associated with increased mortality in elderly and nonelderly trauma patients. J Trauma. 2011;70(2):398–400.
13. Marik PE. Iatrogenic salt water drowning and the hazards of a high central venous pressure. Ann Intensive Care. 2014;4(21).
14. Van PY, Riha GM, Cho SD, et al. Blood volume analysis can distinguish true anemia from hemodilution in critically ill patients. J Trauma. 2011;70(3):646–651.
15. Santry HP, Alam HB. Fluid resuscitation: past, present, and the future. Shock. 2010;33(3):229–241.
16. Kiraly LN, Differding JA, Enomoto TM, et al. Resuscitation with normal saline (NS) vs. lactated ringers (LR) modulates hypercoagulability and leads to increased blood loss in an uncontrolled hemorrhagic shock swine model. J Trauma. 2006;61(1):57–64; discussion 64–65.
17. Barbee RW, Reynolds PS, Ward KR. Assessing shock resuscitation strategies by oxygen debt repayment. Shock. 2010;33(2):113–122.
18. Kaczynski J, Wilczynska M, Hilton J, Fligelstone L. Impact of crystalloids and colloids on coagulation cascade during trauma resuscitation-a literature review. Emergency Medicine and Health Care. 2013;1(1).
19. Chowdhury AH, Cox EF, Francis ST, et al. A randomized, controlled, double-blind crossover study on the effects of 2-L infusions of 0.9% saline and plasma-lyte(R) 148 on renal blood flow velocity and renal cortical tissue perfusion in healthy volunteers. Ann Surg. 2012;256(1):18–24.
20. Mathes DD, Morell RC, Rohr MS. Dilutional acidosis: Is it a real clinical entity? Anesthesiology.1997;86(2):501–503.
21. Schreiber MA. The use of normal saline for resuscitation in trauma. J Trauma Acute Care. 2011;70(5 Suppl):S13–14.
22. Williams EL, Hildebrand KL, Mccormick SA, et al. The effect of intravenous lactated ringer’s solution versus 0.9% sodium chloride solution on serum osmolality in human volunteers. Anesth Analg. 1999;88(5):999–1003.
23. Martini WZ, Pusateri AE, Uscilowicz JM, et al. Independent Contributions of Hypothermia and Acidosis to Coagulopathy in Swine. J Trauma. 2005;58(5):1002–1010.
24. Martini WZ, Cortez DS, Dubick MA. Comparisons of normal saline and lactated Ringer’s resuscitation on hemodynamics, metabolic responses, and coagulation in pigs after severe hemorrhagic shock. Scand J Trauma Resusc Emerg Med. 2013;21(86).
25. Sorenson B, Fries D. Emerging treatment strategies for trauma-induced coagulopathy. Br J Surg.2012;99(Suppl 1):40–50.
26. Meng ZH, Wolberg AS, Monroe DM 3rd, et al. The effect of temperature and pH on the activity of factor VIIa: implications for the efficacy of high-dose factor VIIa in hypothermic and acidotic patients. J Trauma.2003;55(5):886–891.
27. Jabaley C, Dudaryk R. Fluid Resuscitation for Trauma Patients: Crystalloids Versus Colloids. Current Anesthesiology Reports. 2014;4(3):216–224.
28. Robinson BRH, Cohen MJ, Holcomb JB, et al. Risk factors for the development of acute respiratory distress syndrome following hemorrhage. Shock. 2017. [Epub ahead of print.]
29. Dutton RP. Damage Control Anesthesia. International TraumaCare. 2005:197–201.



  • TELEFUNKEN DESFIBRILADOR 
    Tecnologia Alemana
    6 años de Garantia
    Libre de Mantenimiento 
    El mas ECONOMICO

    Vendemos en España y Rep. Dominicana
    Hacemos entrega del Sistema Completo

    eeiispain@gmail.com

    “UNA VIDA NO TIENE PRECIO”

    TELEFUNKEN AED DISPONIBLE EN TODA AMERICA 6 AÑOS DE GARANTIA (ECONOMICO) http://goo.gl/JIYJwk

    Follow me / INVITA A TUS AMIGOS A SEGUIRNOS

    Contactos:    eeiispain@gmail.com
    https://www.facebook.com/DrRamonReyesMD/

viernes, 6 de enero de 2017

Blood in the Prehospital side. Transfusion

 
Blood in the Prehospital side. Transfusion

Blood in the Air

Increasingly, civilian air ambulance providers are carrying blood products onboard their aircraft—potentially life-saving for patients, but a challenging process for operators and staff

 

This article is reproduced with permission of Waypoint AirMed & Rescue,www.waypointmagazine.com. Waypoint AirMed & Rescue Magazine is the undisputed No.1 publication for the international air ambulance and air rescue community. Covering fixed-wing and rotary aircraft, and from private and state air ambulance operators to coast guards, armed forces, police aviation and aerial fire fighting services worldwide, Waypoint offers an unmatched, regular and expert resource to these industries.
Air ambulance medics arriving at the scene of an emergency will in many cases find a patient who has lost a dangerous amount of blood, making every second count between arrival, diagnosis and treatment. Until relatively recently, it was typical for medics to either use a saline solution to replace the volume lost–although this does not replace the oxygen-carrying ability of the shed blood–or wait for blood supplies to be transported from local hospitals by police or ground ambulances, a time-consuming methodology, potentially complicated by a lack of blood supplies at hospitals, or any number of possible hindrances, from heavy traffic to impassable terrain. However, this is starting to change.
In 2011, Australia’s Ambulance Victoria announced it had become the first paramedic-operated helicopter emergency medical service (HEMS) provider in the world to begin transporting and transfusing blood on its own rotary and fixed-wing aircraft.
The organisation’s chief executive officer Greg Sassella said at the time: “People who suffer serious external or internal bleeding as a result of car and other accidents can deteriorate quickly. Paramedics routinely provide fluid through a drip to help stabilise injured patients, but the most effective way of treating significant blood loss is with a blood transfusion. Seriously injured patients will now have the benefits of receiving blood in the field and whilst en route to hospital. Blood carries oxygen that is vital to major organs including the brain and as a result it gives a patient their best chance of survival.”
The process of transporting blood, particularly by air, with the attendant issues surrounding air pressure, temperature, etc., is both complex and costly, and aeromedical providers have only very recently started carrying blood onboard their aircraft–Shannon AirMed 1, a West Texas, US-based air ambulance, is a relative anomaly in that it adopted an early version of the process back in 2002.
While Ambulance Victoria began transporting blood in 2011, London’s Air Ambulance (LAA), the HEMS charity that covers the UK capital, became the first UK helicopter service to adopt the process in March 2012, and Air Med 1, another Texas-based air ambulance which covers Houston, started carrying blood on all its flights as of April this year. German fixed-wing air ambulance provider Med Call also implemented blood transportation facilities relatively recently.
These organisations’ medical aircraft—with more providers gradually adopting the process—now carry around four units of O-negative red blood cell concentrate, as O-negative is a universal donor group that can be given reasonably safely to any patient, regardless of their own blood type. Benefits
Clinically speaking, the benefits for patients are manifold. Red blood cells carry oxygen, thus when blood is lost, the patient’s ability to transport the necessary amount of oxygen to all areas of the body is dangerously diminished, and although saline-based options are effective enough to save lives, it doesn’t take a clinician to see that a transfusion of red blood cells is the better option.
“We have already seen patients surviving to delivery at hospital, where they receive the definitive care for their injuries, who may not have survived this part of their journey without the transfusion of the red cells,” says Gary Wareham, clinical manager for the UK’s Kent, Surrey and Sussex Air Ambulance, which began carrying blood in February of this year.

LAA’s lead clinician Dr Anne Weaver cites patients suffering from non-compressible haemorrhage as an example: “[Non-compressible haemorrhage] can only be controlled by invasive techniques such as surgery or interventional radiology. Many of these patients are compromised before they reach hospital. Even in an urban setting such as London, patients may not reach hospital in time to receive a blood transfusion. This is particularly well demonstrated for trapped patients e.g. in road traffic collisions, or unconscious patients who are found a while after the initial injury.”
In rural settings, Weaver adds, long journey times from the scene of the incident to hospital will also often mean potentially life-threatening delays between accident and full surgical control. “If a patient has lost a significant amount of blood and has gone into cardiac arrest,” Weaver goes on to say, “it is unlikely that the administration of crystalloid fluid will result in a return of spontaneous circulation. However, if you are able to give blood to these patients, it may be successful. If you have lost a large amount of blood, it needs to be replaced with blood in order to perfuse organs with oxygen. Crystalloid fluid does not carry oxygen and as such will not result in perfusion of the brain and other vital organs. Traumatic cardiac arrest due to hypovolaemia has a dismal outcome in the absence of blood transfusion and damage control techniques.”
Weaver believes that carrying blood will dramatically increase the survival rate for such patients; indeed, LAA has already been able to resuscitate patients at the scene of an accident through this technique—patients that would likely otherwise have died before reaching hospital.
Process
In-air blood transportation is logistically challenging, as air ambulances must store and carry blood at no lower than 2°C (36°F) and no higher than 8°C (46°F), in line with industry standards, but also be able to warm it to near body temperature so it can be safely given to patients, when many of the protective safeguards of a hospital operating environment are not present. If these strict temperature levels are not maintained, blood can be damaged, lose its effectiveness or even become dangerous for a patient.
“As blood supplies are limited, they are extremely valuable and strict guidelines are in place to ensure proper handling and record-keeping to guarantee that none is wasted,” explains Ambulance Victoria team manager Murray Barkmeyer. “The blood is stored in specially designed, temperature-controlled and alarmed fridges at our air ambulance bases. They are carried in temperature-controlled blood shippers that are loaded into the aircraft at the start of the shift.”
Blood products have a shelf life of 42 days, but Ambulance Victoria rotates its stocks on a 14-day timetable. “Any blood not used in that time is taken back under temperature-controlled transport to the hospital…where it can be used, to ensure there is no wastage,” adds Barkmeyer.
German fixed-wing air ambulance provider Med Call, as detailed in a presentation by their medical director Marcus Tursch at the International Travel Insurance Conference in Lisbon in 2011, uses powered cool boxes (developed in partnership with the German Blood Donor and Transfusion Service) in order to keep blood at suitable temperatures through long-duration missions. These have been shown to perform well when plugged in—for example by hooking them up to a plane’s inverter—though less favourably when un-powered, or ‘passive’. Loss of power for around 30 minutes is viewed as acceptable, however, as the boxes’ active compressor and passive insulation can keep temperatures below 10°C (50°F), but, as Tursch told Waypoint: “Performance is behind our expectations under tropical conditions. We know this from our thermologger protocols [which monitor temperatures during transport to show that blood is maintained at regulation levels before transfusion]. For bridging times without an available power source, [such as at] security checks and border police or hotel check-in, we carry a transportable, external power source with us.”
LAA uses Cool Logistics’ Credo Thermal Isolation Chambers (TICs), which surround the payload using a phase change material (PCM) to control the temperature. The PCM changes from a liquid to a solid state at a temperature different from that at which water changes, and by adding various chemicals to the substance, the phase change temperature can be altered, making it an ideal material to use for such a temperature-sensitive process. As the temperature of the blood cannot fall lower than 2°C (36°F), using ice is out of the question.
“Phase change materials are specifically formulated for the unique needs of diverse medical materials from super frozen tissue to room-temperature and fridge-temperature vaccines and pharmaceuticals,” a spokesperson for LAA told Waypoint when the organisation first adopted the process. “The boxes are also returnable and resuable, making [them] an environmentally-friendly option.”
Weaver goes into more detail about the requirements: “[We] investigated different storage options. The container needed to be robust, lightweight and weatherproof. Ideally, the storage box would not require batteries or a power source. This avoided the requirement and expense of airworthiness testing. Affordability was an important consideration as many air ambulances are charitably funded.”
The Golden Hour boxes that the charity now uses ‘can hold four units of packed red blood cells (PRBC) at steady-state temperature (2°C to 6°C – 36°F to 43°F) for 48 to 72 hours’. They contain a data logger, through which temperature data can be downloaded in order to show compliance with regulations.
“Blood which has not been used can be returned to the transfusion stock for use in other areas,” adds Weaver. “The box had already survived rigorous testing by the armed forces in Afghanistan.”
Regulations
So, why has in-air blood transportation been such a recent development for most organisations? One of the primary issues—in the UK, at least—has been regulatory, says Gary Wareham.
“From my experience,” Wareham elaborates, “the reasons for this [delay in implementing the procedure] have been the difficulties of working within the UK legislation with regard to the Cold Chain Management [the 2°C to 6°C temperature stipulation] and the traceability requirements [whereby each unit of blood product needs to be fully traceable from donor to recipient]. These requirements are easy to control and monitor in hospitals. A large part of our project was to identify transfusions departments who were prepared to explore the possibilities of these requirements being achieved in the pre-hospital world.” He adds: “The challenge to our crews is the maintenance of the traceability of the units ... often at a busy and stressful scene. This generates the inevitable paperwork at both the scene and on the base. We aim to achieve 100-per-cent traceability as required by UK legislation.”
The UK’s Medicines and Healthcare Products Regulatory Agency (MHRA), which regulates medicines and medical devices, mandates that full traceability is ensured ‘from donation to the point of delivery for not less than 30 years’, and final responsibility for traceability rests with the destination hospital (even if, for example, a transfusion is carried out en route from a different hospital), two of many stipulations that add to the challenging—and costly—nature of the process. “The rules and regulations make the practice of blood transfusion necessarily onerous,” says Weaver, “which on the face of it can appear to be impossible to negotiate for non-hospital based organisations, e.g. air ambulances. Blood transfusion is governed by strict legislation and extensive guidance. Hospital transfusion departments are quite rightly protective of the use of blood products. Legislation exists to ensure that patients are protected from transfusion errors and that products are not wasted or used inappropriately.”
Likely to Continue?
So, is uptake of the process among air ambulance organisations likely to increase? The professionals Waypoint spoke to seem to think so.
“In the two years since we began carrying blood onboard the first helicopter, it has been used more than 70 times,” says Ambulance Victoria’s Murray Barkmeyer, “with the majority of cases involving multi-trauma car accidents, while one patient who was hurt in an explosion was also given an in-flight transfusion. It has also been used in inter-hospital transfers involving life threatening haemorrhage, including an Irish backpacker who had an ectopic pregnancy while in a remote town in Victoria’s far east.”
On the financial side of things, costs vary depending on the organisation, be it a HEMS charity that is tied to a particular hospital, or a private air ambulance .

“We have an agreement in place with the National Blood Service (NBS) at the John Radcliffe Hospital, part of the Oxford University Hospitals Trust for the provision for O-neg blood,” AirMed UK’s Jane Topliss told Waypoint. “There is a cost attached to the provision of these blood products, which we have to pass on to the client. If there is a potential requirement identified, we will always carry a minimum of four units of blood with the cost associated being approximately £600 in total (£150 per unit).”
There are even variations between different UK HEMS charities, as Clive Dickin, national director of the Association of Air Ambulances, comments. “The equipment onboard the aircraft tends to be relatively cheap,” he explains. “The costs are more logistical than anything. London’s Air Ambulance, for example, is based on top of a major trauma centre, so has instant access to blood, making delivery and storage pretty straightforward. For others, the blood must be transported to the air ambulance, which can be costly, and as most air ambulances aren’t based at major trauma centres, hospitals need to be reassured that stocks won’t be wasted in transfer. However, there is definitely a desire to start taking [the process] up all around the UK.”
Both Dr Anne Weaver and Gary Wareham say that their respective organisations have encountered no major drawbacks or unforeseen issues. “LAA has delivered over 100 pre-hospital transfusions during the first 12 months of this innovation,” says Weaver. “The teams have a traceability record of 100 per cent, which is superior to that of many hospital departments. Wasted blood products must be avoided at all costs and unnecessary waste would be a drawback as O-negative blood is a precious resource. Only one unit of blood has been wasted due to a communication error with the transfusion laboratory.”
Marcus Tursch is also confident that Med Call will continue to utilise the process: “We will continue working with the powered cool box, as we did not find a passive system to guarantee the cooling chain on an overnight mission. However, I think the most important thing is to use a thermologger [and] a recording thermometer inside the cool box to prove that the cooling chain is not interrupted.”
In the UK, helicopter charity the Thames Valley and Chiltern Air Ambulance Service has also started carrying blood, as has fixed-wing provider CEGA Air Ambulance.
“Other air ambulances have shown interest in the results of this work,” adds Weaver, “and may well decide to offer this additional service.”
So long as organisations can adhere to the strict regulatory requirements—and overcome any potential financial barriers—the future seems bright for in-air blood transport and, by extension, for patients.
“I’m sure that we are one of the first [organisations] of many,” concludes Wareham. “The benefits of prehospital blood transfusions far outweigh any procedural ‘hassles’, and if we are honest it is something that we have wanted for some time. The next step will be to look at other blood products that may be beneficial to the patient, such as those that will assist in the clotting process. Onwards and upwards!”

Transfusions During Hospital Transport May Help Trauma Patients Survive Study compared short-term survival in severely injured patients
SATURDAY, Nov. 16, 2013 (HealthDay News) -- Giving blood transfusions to severely injured patients while they're on the way to the hospital could save their lives, at least in the short term, new research suggests.

The study included 97 trauma patients who received transfusions of either plasma or red blood cells in a ground or air ambulance before they arrived at the hospital. These patients were compared with 480 trauma patients who didn't receive transfusions on the way to the hospital.
Patients who received the transfusions were 8 percent less likely to die within six hours after arriving at the hospital, compared to those in the comparison group. Those in the transfusion group were also 13 percent more likely to survive to hospital discharge, although the researchers said this was not statistically significant.
The study was scheduled to be presented Saturday at the annual meeting of the American Heart Association in Dallas.
"Earlier, effective intervention seems to have the best effect on outcomes, such as pre-hospital transfusions on trauma patients that can save lives," study lead researcher Dr. John Holcomb said in a heart association news release.
Trauma is the leading cause of death in people aged 44 and younger in the United States, and the leading cause of years of life lost, according to the researchers.
Because the study was presented at a medical meeting, the data and conclusions should be viewed as preliminary until published in a peer-reviewed journal.
More information
The American College of Emergency Physicians offers injury prevention tips.
Copyright © 2012 HealthDay. All rights reserved.

U.S. and German medics doing fresh whole blood (auto)transfusion during a unit internal Prolonged Field Care exercise.
How does your unit practice fresh whole blood transfusions?

_____________________________________________
Auto-transfusion is taking blood out of the role-player patient before the exercise and putting it back in the same patient during the scenario as if it was drawn from someone else. It is far more confidence building than using food coloring fake blood transfusions on mannequins (but thats good for teaching first and for non-medics.) I recommend units have their medics do it instead of just talking through, watching a video, etc.
This is incredibly low risk with high reward. You can even recommend to take only one bag from one patient at a time, or keep the training lanes in completely divided areas, so they don't get mixed up and strictly enforce labeling them, further lowering the risk.
I have had my non-medics practice this on my own veins. 68W's will in the near future graduate knowing FWB transfusions...and it's the first option for fluid resuscitation. Being behind in medicine is a choice in the age of information. If you don't trust medics to do transfusions but they can do crics then you need to re-evaluate the teaching of your medics and who you are letting deploy.
If you need any resources or have any questions let us know.