Indications and transfusion protocol

Show Notes

Core EM Modular CME Course

Maximize your commute with the new Core EM Modular CME Course, featuring the most essential content distilled from our top-rated podcast episodes. This course offers 12 audio-based modules packed with pearls! Information and link below. 

Course Highlights:

• Credit: 12.5 AMA PRA Category 1 Credits™
• Curriculum: Comprehensive coverage of Core Emergency Medicine,  with 12 modules spanning from Critical Care to Pediatrics.
• Cost:
  • Free for NYU Learners
  • $250 for Non-NYU Learners

Click Here to Register and Begin Module 1

What is prehospital blood transfusion

• Administration of blood products in the field prior to hospital arrival

• Aimed at patients in hemorrhagic shock

Why this matters

• Traditional US prehospital resuscitation relied on crystalloid

• ED and trauma care now prioritize early blood

• Hemorrhage occurs before hospital arrival

• Delays to definitive hemorrhage control are common

• Earlier blood may improve survival

Supporting rationale

• ATLS and trauma paradigms emphasize blood over fluid

• National organizations support prehospital blood when feasible

• EMS already manages high risk, time sensitive interventions

Evidence overview

• Data are mixed and evolving

  • COMBAT: no benefit

  • PAMPer: mortality benefit

  • RePHILL: no clear benefit

• Signal toward benefit when transport time exceeds ~20 minutes

• Urban systems still experience long delays due to traffic and geography

• LA County median time to in hospital transfusion ~35 minutes

LA County program

• ~2 years of planning before launch

• Pilot began April 1

• Partnerships:

  • LA County Fire

  • Compton Fire

  • Local trauma centers

  • San Diego Blood Bank

• 14 units of blood circulating in the field

• Blood rotated back 14 days before expiration

• Ultimately used at Harbor UCLA

• Continuous temperature and safety monitoring

Indications used in LA County

• Focused rollout

• Trauma related hemorrhagic shock

• Postpartum hemorrhage

Physiologic criteria:

• SBP < 70

• Or HR > 110 with SBP < 90

• Shock index ≥ 1.2

• Witnessed traumatic cardiac arrest

Products:

• One unit whole blood preferred

• Two units PRBCs if whole blood unavailable

Early experience

• ~28 patients transfused at time of discussion

• Evaluating:

  • Indications

  • Protocol adherence

  • Time to transfusion

  • Early outcomes

• Too early for outcome conclusions

California collaboration

• Multiple active programs:

  • Riverside (Corona Fire)

  • LA County

  • Ventura County

• Additional programs planned:

  • Sacramento

  • San Bernardino

• Programs meet monthly as CalDROP

• Focus on shared learning and operational optimization

Barriers and concerns

• Trauma surgeon concerns about blood supply

• Need for system wide buy in

• Community engagement

• Patients who may decline transfusion

• Women of childbearing age and alloimmunization risk

• Risk of HDFN is extremely low

• Clear communication with receiving hospitals is essential

Future direction

• Rapid national expansion expected

• Greatest benefit likely where transport delays exist

• Prehospital Blood Transfusion Coalition active nationally

• Major unresolved issue: reimbursement

• Currently funded largely by fire departments

• Sustainability depends on policy and payment reform

Take-Home Points

• Hemorrhagic shock is best treated with blood, not crystalloid

• Prehospital transfusion may benefit patients with prolonged transport times

• Implementation requires strong partnerships with blood banks and trauma centers

• Early data are promising, but patient selection remains critical

• National collaboration is key to sustainability and future growth