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Prehospital Blood Product Administration Opportunities in Ground Transport ALS EMS – A Descriptive Study

  • Felicia M. Mix (a1), Martin D. Zielinski (a2), Lucas A. Myers (a3), Kathy S. Berns (a3), Anurahda Luke (a1) (a3), James R. Stubbs (a4), Scott P. Zietlow (a2), Donald H. Jenkins (a5) and Matthew D. Sztajnkrycer (a1)...



Hemorrhage remains the major cause of preventable death after trauma. Recent data suggest that earlier blood product administration may improve outcomes. The purpose of this study was to determine whether opportunities exist for blood product transfusion by ground Emergency Medical Services (EMS).


This was a single EMS agency retrospective study of ground and helicopter responses from January 1, 2011 through December 31, 2015 for adult trauma patients transported from the scene of injury who met predetermined hemodynamic (HD) parameters for potential transfusion (heart rate [HR]≥120 and/or systolic blood pressure [SBP]≤90).


A total of 7,900 scene trauma ground transports occurred during the study period. Of 420 patients meeting HD criteria for transfusion, 53 (12.6%) had a significant mechanism of injury (MOI). Outcome data were available for 51 patients; 17 received blood products during their emergency department (ED) resuscitation. The percentage of patients receiving blood products based upon HD criteria ranged from 1.0% (HR) to 5.9% (SBP) to 38.1% (HR+SBP). In all, 74 Helicopter EMS (HEMS) transports met HD criteria for blood transfusion, of which, 28 patients received prehospital blood transfusion. Statistically significant total patient care time differences were noted for both the HR and the SBP cohorts, with HEMS having longer time intervals; no statistically significant difference in mean total patient care time was noted in the HR+SBP cohort.


In this study population, HD parameters alone did not predict need for ED blood product administration. Despite longer transport times, only one-third of HEMS patients meeting HD criteria for blood administration received prehospital transfusion. While one-third of ground Advanced Life Support (ALS) transport patients manifesting HD compromise received blood products in the ED, this represented 0.2% of total trauma transports over the study period. Given complex logistical issues involved in prehospital blood product administration, opportunities for ground administration appear limited within the described system.

MixFM, ZielinskiMD, MyersLA, BernsKS, LukeA, StubbsJR, ZietlowSP, JenkinsDH, SztajnkrycerMD. Prehospital Blood Product Administration Opportunities in Ground Transport ALS EMS – A Descriptive Study. Prehosp Disaster Med. 2018;33(3):230236.


Corresponding author

Correspondence: Matthew D. Sztajnkrycer, MD, PhD Associate Professor of Emergency Medicine Mayo Clinic GE-GR-G410 200 1st Street SW Rochester, Minnesota 55905 USA E-mail:


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Conflicts of interest: The authors report no conflict of interests. Portions of this manuscript were presented at the 20th World Association for Disaster and Emergency Medicine Congress on Disaster and Emergency Medicine; Toronto, Ontario; April 2017.



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1. National Center for Injury Control and Prevention. 10 Leading Causes of Death, United States 2015. Centers for Disease Control and Prevention. Accessed June 18, 2017.
2. National Center for Injury Control and Prevention. 10 Leading Causes of Death, United States Highlighting Unintentional Injury Deaths, United States 2105. Accessed June 18, 2017.
3. World Health Organization. Fact Sheet: The Top 10 Causes of Death – Updated January 2017. Accessed June 18, 2017.
4. Kauvar, DS, Lefering, R, Wade, CE. Impact of hemorrhage on trauma outcome: an overview of epidemiology, clinical presentations, and therapeutic considerations. J Trauma. 2006;60(6 Suppl):S3-S11.
5. Eastridge, BJ, Mabry, RL, Seguin, P, et al. Death on the battlefield (2001-2011): implications for the future of combat casualty care. J Trauma Acute Care Surg. 2012;73(6 Suppl 5):S431-S437.
6. Haut, ER, Kalish, BT, Cotton, BA, et al. Prehospital intravenous fluid administration is associated with higher mortality in trauma patients: a national trauma data bank analysis. Ann Surg. 2011;253(2):371-378.
7. Hussmann, B, Lefering, R, Waydhas, C, et al. the Trauma Registry of the German Society for Trauma Surgery. Does increased prehospital replacement volume lead to a poor clinical course and an increased mortality? A matched-pair analysis of 1896 patients of the Trauma Registry of the German Society for Trauma Surgery who were managed by an emergency doctor at the accident site. Injury. 2013;44(5):611-617.
8. Fries, CA, Midwinter, MJ. Trauma resuscitation and damage control surgery. Surgery (Oxford). 2010;28(11):563-567.
9. Midwinter, MJ. Damage control surgery in the era of damage control resuscitation. J R Army Med Corps. 2009;155(4):323-326.
10. Ball, CG. Damage control resuscitation: history, theory, and technique. Can J Surg. 2014;57(1):55-60.
11. Stensballe, J, Ostrowski, SR, Johansson, PI. Haemostatic resuscitation in trauma: the next generation. Curr Opin Crit Care. 2016;22(6):591-597.
12. Powell, EK, Hinckley, WR, Gottula, A, Hart, KW, Lindsell, CJ, McMullan, JT. Shorter times to packed red blood cell transfusion are associated with decreased risk of death in traumatically injured patients. J Trauma Acute Care Surg. 2016;81(3):458-462.
13. Cotton, BA, Reddy, N, Hatch, QM, et al. Damage control resuscitation is associated with a reduction in resuscitation volumes and improvement in survival in 390 damage control laparotomy patients. Ann Surg. 2011;254(4):598-605.
14. Fisher, AD, Miles, EA, Cap, AP, Strandenes, G, Kane, SF. Tactical damage control resuscitation. Mil Med. 2015;180(8):869-875.
15. Jenkins, DH, Rappold, JF, Badloe, JF, et al. THOR position paper on remote damage control resuscitation: definitions, current practice, and knowledge gaps. Shock. 2014;41(01):3-12.
16. Strandenes, G, De Pasquale, M, Cap, AP, et al. Emergency whole-blood use in the field: a simplified protocol for collection and transfusion. Shock. 2014;41(Suppl 1):76-83.
17. Borwn, JB, Sperry, SJ, Fombona, A, Billiar, TR, Peitzman, AB, Guyette, FX. Pre-trauma center red blood cell transfusion is associated with improved early outcomes in air medical trauma patients. J Am Coll Surg. 2015;220(5):797-808.
18. Yann, D, Habas, S, Malan, L, Escarment, J, David, J-S, Peyrefitte, S. Tactical damage control resuscitation in austere military environments. J R Army Med Corps. 2016;162(6):419-427.
19. Karl, A, Pham, T, Yanosky, JD, Lubin, J. Variability of uncross-matched blood use by helicopter EMS programs in the United States. Prehosp Emerg Care. 2016;20(6):688-694.
20. Stubbs, JR, Zielinski, MD, Berns, KS, et al. How we provide thawed plasma for trauma patients. Transfusion. 2015;55(8):1830-1837.
21. Capone, AC, Safar, P, Stezoski, W, Tisherman, S, Peitzman, AB. Improved outcome with fluid restriction in treatment of uncontrolled hemorrhagic shock. J Am Coll Surg. 1995;180(1):49-56.
22. Craig, RL, Poole, GV. Resuscitation in uncontrolled hemorrhage. Am Surg. 1994;60(1):59-62.
23. Bickell, WH, Wall, MH, Pepe, PE, et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med. 1994;331(17):1105-1109.
24. Brohi, K, Singh, J, Heron, M, et al. Acute traumatic coagulopathy. J Trauma. 2003;54(6):1127-1130.
25. MacLeod, JB, Lynn, M, McKenney, MG, et al. Early coagulopathy predicts mortality in trauma. J Trauma. 2003;55(1):39-44.
26. Blackbourne, LH. Combat damage control surgery. Crit Care Med. 2008;36(7 Suppl):S304-S310.
27. Holcomb, JB, Jenkins, D, Rhee, P, et al. Damage control resuscitation: directly addressing the early coagulopathy of trauma. J Trauma. 2007;62(2):307-310.
28. Smith, JB, Pittet, J-F. Hypotensive resuscitation. Curr Anesthesiol Rep. 2014;4(3):209-215.
29. Basu, D, Kulkarni, R. Overview of blood components and their preparation. Indian J Anaesth. 2014;58(5):529-537.
30. Shuja, F, Shults, C, Duggan, M, et al. Development and testing of freeze-dried plasma for the treatment of trauma-associated coagulopathy. J Trauma. 2008;65(5):975-985.
31. Spoerke, N, Zink, K, Cho, SD, et al. Lyophilized plasma for resuscitation in a swine model of severe injury. Arch Surg. 2009;144(9):829-834.
32. Lee, TH, Van, PY, Spoerke, NJ, et al. The use of lyophilized plasma in a severe multi-injury pig model. Transfusion. 2013;53(Suppl 1):72S-79S.
33. Zehtabchi, S, Nishijima, DK. Impact of transfusion of fresh-frozen plasma and packed red blood cells in a 1:1 ratio on survival of emergency department patients with severe trauma. Acad Emerg Med. 2009;16(5):371-378.
34. Sperry, JL, Ochoa, JB, Gunn, SR, et al. Inflammation the Host Response to Injury Investigators. An FFP:PRBC transfusion ratio >/=1:1.5 is associated with a lower risk of mortality after massive transfusion. J Trauma. 2008;65(5):986-993.
35. Duchesne, JC, Hunt, JP, Wahl, G, et al. Review of current blood transfusions strategies in a mature level I trauma center: were we wrong for the last 60 years? J Trauma. 2008;65(2):272-276; discussion 276-278.
36. Teixeira, PG, Inaba, K, Shulman, I, et al. Impact of plasma transfusion in massively transfused trauma patients. J Trauma. 2009;66(3):693-697.
37. Holcomb, JB, Tilley, BC, Baranjuk, S, et al; for the PROPPR Study Group. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA. 2015;313(5):471-482.
38. EMS1 Staff. NC paramedics to begin performing blood transfusions. September 30, 2016. Accessed June 18, 2017.
39. Uhl N. Blood on the Ground. The Official Cypress Creek EMS News Page. August 25, 2016. Accessed June 18, 2017.



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