Powered by the Evidence-based Practice Centers
Evidence Reports All of EHC
Evidence Reports All of EHC

SHARE:

FacebookTwitterFacebookPrintShare

Prehospital EMS Blood Transfusion

Key Questions May 28, 2024
Download the file for this report here.

To support the development of a systematic review (SR) on the feasibility, effectiveness, and safety of blood and blood product transfusions administered in the prehospital setting. The statement of work (SOW) will set the scope for a medium topic refinement and an option for a medium or large SR. The results of the SR will inform future prehospital care evidence-based guidelines (EBG), protocols, and state and local EMS agency decision-making.

The NHTSA Office of Emergency Medical Services (OEMS) mission is to reduce death and disability by providing leadership and coordination to the emergency medical services (EMS) community in assessing, planning, developing, and promoting comprehensive, evidence-based emergency medical services systems. 

NHTSA is the federal leader for motor vehicle and traffic safety, with a history of successfully promoting and advancing injury prevention in its policies, programs, and practices. EMS also plays a significant role in ensuring the safety and care of crash victims across the nation's highways and roadways. The U.S. Department of Transportation's (DOT) 2022 National Roadway Safety Strategy (NRSS) emphasizes a safe system approach that identifies post-crash care as one of five key objectives in creating a transportation system safe for all people.

Motor vehicle crashes are a leading cause of trauma-related deaths, often resulting in severe bleeding and hypovolemic shock. The potential impact of prehospital blood transfusion in such scenarios is substantial, as early intervention could mitigate the consequences of hemorrhage and improve survival rates. Recognizing the importance of evidence-based practices, there is a pressing need for a systematic review of the existing literature on prehospital blood transfusion. This review would critically assess the available studies, evaluating the efficacy, safety, and risks of administering blood transfusions in the prehospital environment.

The history of prehospital blood transfusion dates to the early 20th century, with the advent of World War I which highlighted the need for rapid and effective blood transfusions on the battlefield. However, the logistics and limitations of early medical technologies made prehospital blood transfusions a challenging feat. Over the years, advancements in medical science and technology have facilitated the development of more portable and efficient blood transfusion methods. Despite these improvements, prehospital blood transfusion remains a complex and debated topic, as the benefits must be carefully weighed against potential risks and logistical challenges.

Prehospital blood transfusion studies and pilot programs have explored the feasibility, safety, and effectiveness of such interventions. While some regions have implemented programs successfully, the science behind these practices is continually evolving. Training and equipment advances have empowered prehospital providers to administer whole blood and blood components, such as packed red blood cells and plasma, to trauma patients on scene, potentially improving outcomes, particularly in cases of severe hemorrhage.

The results of a systematic review would serve as a crucial resource for prehospital care evidence-based guidelines, protocols, and state and local EMS agency decision-making. By synthesizing the existing evidence, the review would offer insights into the overall effectiveness of prehospital blood transfusion in different contexts, helping to refine guidelines and inform training programs for EMTs and paramedics. Additionally, it could address concerns related to potential adverse effects and logistical challenges, ensuring a balanced approach to implementation. Ultimately, a systematic review would contribute to evidence-based practices in prehospital care, shaping policies that maximize the potential benefits of blood transfusions while minimizing associated risks.

An interagency agreement funded the Agency for Healthcare Research and Quality (AHRQ) for a medium topic refinement with an option for a medium or large systematic review on EMS prehospital blood transfusion.

Approach/Methods

The proposed systematic review will be conducted using a methodology established by the AHRQ EPC program, with the work conducted by a one of AHRQ's designated Evidence-based Practice Centers (EPC). These EPCs develop evidence reports to inform clinical decision-making and actions. The SR would address key questions developed under the topic refinement. The draft key questions are included below.

Key Question 1

  1. What are the comparative benefits and harms of low-titer group O whole blood transfusion compared with component blood therapy transfusion for patients requiring prehospital hemostatic resuscitation?
  2. Are the comparative benefits and harms modified by:
    1. Prehospital emergency medical services protocol (including transfusion volume, adjuvant medication co-administration, or isotonic fluid co-infusion)?
    2. Patient characteristics (including age, gender, nature of illness, or mechanism of injury)?
    3. Characteristics of the emergency medical services system (including air medical versus ground ambulance, personnel certification, or service delivery model)?

Key Question 2

  1. What are the comparative benefits and harms of low-titer group O whole blood transfusion compared with fluid resuscitation for patients requiring prehospital hemostatic resuscitation?
  2. Are the comparative benefits and harms modified by:
    1. Prehospital emergency medical services protocol (including transfusion volume, adjuvant medication co-administration, or isotonic fluid co-infusion)?
    2. Patient characteristics (including age, gender, nature of illness, or mechanism of injury)?
    3. Characteristics of the emergency medical services system (including air medical versus ground ambulance, personnel certification, or service delivery model)?

Key Question 3

  1. What are the comparative benefits and harms of component blood therapy transfusion compared with fluid resuscitation for patients requiring prehospital hemostatic resuscitation?
  2. Are the comparative benefits and harms modified by:
    1. Prehospital emergency medical services protocol (including transfusion volume, adjuvant medication co-administration, or isotonic fluid co-infusion)?
    2. Patient characteristics (including age, gender, nature of illness, or mechanism of injury)?
    3. Characteristics of the emergency medical services system (including air medical versus ground ambulance, personnel certification, or service delivery model)?

Key Question 4

What are the comparative benefits and harms of different protocols for the three hemostatic resuscitation interventions (low-titer group O whole blood, component blood therapy, fluid resuscitation) for patients requiring prehospital hemostatic resuscitation?

  1. Prehospital emergency medical services protocol (including transfusion volume, adjuvant medication co-administration, or isotonic fluid co-infusion)?
  2. Patient characteristics (including age, gender, nature of illness, or mechanism of injury)?
  3. Characteristics of the emergency medical services system (including air medical versus ground ambulance, personnel certification, or service delivery model)?

Key Question 5

What specific areas of future research are essential for closing existing evidence gaps surrounding prehospital hemostatic resuscitation and prehospital blood product transfusion? Consideration should be given to the formulation of precise scientific questions, optimal study design, targeted study populations, and the exploration of various blood transfusion intervention protocols.

Contextual Question 1

What are the implementation facilitators and barriers of effective prehospital blood product transfusion programs? Distinguishing factors may include emergency medical services agency costs, emergency medical services agency reimbursement, cost effectiveness, blood product maintenance and logistics, partnerships with blood banks, medical oversight including real-time medical direction, and diagnostic tools.

PICOSInclusion CriteriaExclusion Criteria
PopulationsPatients requiring prehospital hemostatic resuscitation who are treated in the prehospital setting by emergency medical services cliniciansIndividuals who do not require prehospital hemostatic resuscitation; individuals not treated by emergency medical services clinicians
Intervention and Comparator
  • KQ1: low-titer group O whole blood vs. blood component therapy (i.e., packed red blood cells, fresh frozen plasma, platelets)
  • KQ2: low-titer group O whole blood vs. fluid resuscitation (i.e., 0.9% sodium chloride, Ringer’s lactate, other balanced crystalloid solution, etc.)
  • KQ3: blood component therapy vs. fluid resuscitation
  • KQ4: different protocols for any one of the three hemostatic resuscitation interventions
  • KQ5: n/a
Other type of resuscitation
Outcomes

Patient Health Outcomes (highest priority)

  • Mortality/survival
    • To arrival at hospital
    • To hospital discharge
    • Any period less than or equal to 30 days post-emergency
  • Morbidity after discharge
    • Glasgow Outcome Scale, Glasgow Outcome Scale Extended, Modified Rankin Scale, Cerebral Performance Category
  • Length of Stay
    • Hospital length of stay (days)
    • ICU length of stay (days)

Intermediate Outcomes in the prehospital or ED setting

  • Vital signs
    • Systolic blood pressure
    • Diastolic blood pressure
    • Heart rate
    • Respiratory rate
    • Shock index
    • Glasgow Coma Scale
      • Alert, Verbal, Painful, Unconscious
      • Body temperature
      • Lactate level
      • End tidal Co2
    • Time from EMS arrival to initial transfusion of blood product
    • Amount of blood product transfused (prehospital and hospital) vs. (hospital only)

Adverse events/harms

  • allergic reaction
  • febrile non-hemolytic reaction
  • acute hemolytic reaction
  • transfusion-related acute lung injury [TRALI]
  • transfusion-associated circulatory overload [TACO]
  • infection
  • iron overload
  • citrate toxicity
  • delayed definitive care arrival time
 
Setting
  • Prehospital
  • ED only if needed to fill important gaps where there are no prehospital studies
  • International studies in English language
 
Study Design
  • RCTs
  • Prospective comparative studies
  • Retrospective comparative studies
  • Case control studies
  • Systematic reviews (we will use reference lists to identify studies for possible inclusion)
  • Case series
  • Descriptive studies
  • Letters to the editor
  • Opinion papers
  • Studies published prior to 1990

Draft Analytic Framework

This figure depicts the Logic Model for Key Questions (KQs) 1, 2, 3, 4, and 5. In general, the figure illustrates the comparative effectiveness of various blood and fluid interventions for patients requiring prehospital hemostatic resuscitation. Specific interventions/comparisons include comparative benefits and harms of low-titer group O whole blood transfusion compared with component blood therapy transfusion (KQ1), comparative benefits and harms of low-titer group O whole blood transfusion compared with fluid resuscitation (KQ2), comparative benefits and harms of component blood therapy transfusion compared with fluid resuscitation (KQ3), comparative benefits and harms of different protocols for the three hemostatic resuscitation interventions (low-titer group O whole blood, component blood therapy, fluid resuscitation) (KQ4) and specific areas of future research that are essential for closing existing evidence gaps surrounding prehospital hemostatic resuscitation and prehospital blood product transfusion (KQ5).  The framework begins on the left with a rectangular box that includes the population of patients requiring hemostatic resuscitation in a prehospital setting.   To the right of the population description box is a horizontal arrow above which sits a second rectangular box that includes the interventions of low-titer group 0 whole blood transfusion, component blood therapy transfusions and fluid resuscitation.  Below the horizontal arrow in an s shaped arrow that points to an oval box entitled adverse effects that include allergic reaction, febrile non-hemolytic reaction, acute hemolytic reaction, transfusion-related acute lung injury, delayed definitive care arrival time, transfusion-associated circulatory overload, infection, iron overload and citrate toxicity.  To the right of the interventions box is a horizontal arrow, which leads to a rectangular box entitled intermediate outcomes including vital signs, time from EMS arrival to initial transfusion of blood product and amount of blood product transfused (prehospital and hospital) vs (hospital only).  To the right of the intermediate outcomes box is a horizontal arrow that points to a rectangular box titled final health outcomes which include mortality/survival, morbidity after discharge, length of stay.

 

AcronymsDefinition
AHRQAgency for Healthcare Research and Quality
CO2Carbon Dioxide
DOTDepartment of Transportation
EMSEmergency Medical Services
EMTEmergency Medical Technician
EPCEvidence-Based Practice Centger
NHTSANational Highway and Transportation and Safety Administration
O2Oxygen
OEMSOffice of Emergency Medical Services
RCTRandomized Controlled Trial
SRSystematic Review

  1. Pusateri AE, Moore EE, Moore HB, et al. Association of Prehospital Plasma Transfusion With Survival in Trauma Patients With Hemorrhagic Shock When Transport Times Are Longer Than 20 Minutes: A Post Hoc Analysis of the PAMPer and COMBAT Clinical Trials. JAMA Surg. 2020;155(2):e195085. doi:10.1001/jamasurg.2019.5085
  2. Gruen DS, Guyette FX, Brown JB, et al. Association of Prehospital Plasma With Survival in Patients With Traumatic Brain Injury: A Secondary Analysis of the PAMPer Cluster Randomized Clinical Trial. JAMA Netw Open. 2020;3(10):e2016869. doi:10.1001/jamanetworkopen.2020.16869
  3. Blood product resuscitation mitigates the effects of aeromedical evacuation after polytrauma - PubMed. Accessed March 7, 2024. https://pubmed.ncbi.nlm.nih.gov/34932039/
  4. Gruen DS, Guyette FX, Brown JB, et al. Characterization of unexpected survivors following a prehospital plasma randomized trial. J Trauma Acute Care Surg. 2020;89(5):908-914. doi:10.1097/TA.0000000000002816
  5. Cassignol A, Marmin J, Mattei P, et al. Civilian prehospital transfusion - experiences from a French region. Vox Sang. 2020;115(8):745-755. doi:10.1111/vox.12984
  6. Compliance with the European trauma guidelines: An observational single centre study - PubMed. Accessed March 7, 2024. https://pubmed.ncbi.nlm.nih.gov/29936040/
  7. Puzio TJ, Meyer DE, Heft N, Nealy W, Osborn L. Continuum of Care: A Multiagency Approach to Seamless Warmed Prehospital Whole Blood Resuscitation of a Patient with Noncompressible Truncal Hemorrhage. Prehosp Emerg Care. 2023;27(6):790-793. doi:10.1080/10903127.2022.2104976
  8. Carter AJE, MacDonald RD. Damage control resuscitation initiated in the prehospital and transport setting: A systems approach to increasing access to blood transfusion. CJEM. 2019;21(3):318-320. doi:10.1017/cem.2019.28
  9. Haltmeier T, Benjamin E, Gruen JP, et al. Decreased mortality in patients with isolated severe blunt traumatic brain injury receiving higher plasma to packed red blood cells transfusion ratios. Injury. 2018;49(1):62-66. doi:10.1016/j.injury.2017.07.035
  10. Ladhani HA, Ho VP, Charbonnet CC, et al. Dose-dependent association between blood transfusion and nosocomial infections in trauma patients: A secondary analysis of patients from the PAMPer trial. J Trauma Acute Care Surg. 2021;91(2):272-278. doi:10.1097/TA.0000000000003251
  11. Rehn M, Weaver A, Brohi K, et al. Effect of Prehospital Red Blood Cell Transfusion on Mortality and Time of Death in Civilian Trauma Patients. Shock. 2019;51(3):284-288. doi:10.1097/SHK.0000000000001166
  12. Broome JM, Nordham KD, Piehl M, et al. Faster Refill in an Urban EMS System Saves Lives: A Prospective Preliminary Evaluation of a Prehospital Advanced Resuscitative Care Bundle. J Trauma Acute Care Surg. Published online January 8, 2024. doi:10.1097/TA.0000000000004239
  13. Moore HB, Tessmer MT, Moore EE, et al. Forgot calcium? Admission ionized-calcium in two civilian randomized controlled trials of prehospital plasma for traumatic hemorrhagic shock. J Trauma Acute Care Surg. 2020;88(5):588-596. doi:10.1097/TA.0000000000002614
  14. Braverman MA, Smith A, Shahan CP, et al. From battlefront to homefront: creation of a civilian walking blood bank. Transfusion. 2020;60 Suppl 3:S167-S172. doi:10.1111/trf.15694
  15. Van Dijck CP, Stansbury LG, Latimer AJ, et al. Hemostatic Resuscitation of Pediatric Trauma Patients During Air Medical Transport: A Retrospective Matched Cohort Study. Air Med J. 2021;40(5):344-349. doi:10.1016/j.amj.2021.04.004
  16. Tonglet M, D’Orio V, Moens D, et al. Impact of a prehospital discrimination between trauma patients with or without early acute coagulopathy of trauma and the need for damage control resuscitation: rationale and design of a multicenter randomized phase II trial. Acta Chir Belg. 2019;119(2):88-94. doi:10.1080/00015458.2018.1470276
  17. Sunde GA, Bjerkvig C, Bekkevold M, et al. Implementation of a low-titre whole blood transfusion program in a civilian helicopter emergency medical service. Scand J Trauma Resusc Emerg Med. 2022;30(1):65. doi:10.1186/s13049-022-01051-z
  18. Rittblat M, Gavish L, Tsur AM, Gelikas S, Benov A, Shlaifer A. Intraosseous administration of freeze-dried plasma in the prehospital setting. Isr Med Assoc J. 2022;24(9):591-595.
  19. Rijnhout TWH, Wever KE, Marinus RHAR, Hoogerwerf N, Geeraedts LMG, Tan ECTH. Is prehospital blood transfusion effective and safe in haemorrhagic trauma patients? A systematic review and meta-analysis. Injury. 2019;50(5):1017-1027. doi:10.1016/j.injury.2019.03.033
  20. Shackelford SA, Gurney JM, Taylor AL, et al. Joint Trauma System, Defense Committee on Trauma, and Armed Services Blood Program consensus statement on whole blood. Transfusion. 2021;61 Suppl 1:S333-S335. doi:10.1111/trf.16454
  21. Garner AA, Bartolacci RA. Massive prehospital transfusion in multiple blunt trauma. Med J Aust. 1999;170(1):23-25. doi:10.5694/j.1326-5377.1999.tb126860.x
  22. Hanna K, Bible L, Chehab M, et al. Nationwide analysis of whole blood hemostatic resuscitation in civilian trauma. J Trauma Acute Care Surg. 2020;89(2):329-335. doi:10.1097/TA.0000000000002753
  23. Tucker H, Avery P, Brohi K, et al. Outcome measures used in clinical research evaluating prehospital blood component transfusion in traumatically injured bleeding patients: A systematic review. J Trauma Acute Care Surg. 2021;91(6):1018-1024. doi:10.1097/TA.0000000000003360
  24. Moore EE, Chin TL, Chapman MC, et al. Plasma first in the field for postinjury hemorrhagic shock. Shock. 2014;41 Suppl 1(0 1):35-38. doi:10.1097/SHK.0000000000000110
  25. van Turenhout EC, Bossers SM, Loer SA, Giannakopoulos GF, Schwarte LA, Schober P. Pre-hospital transfusion of red blood cells. Part 1: A scoping review of current practice and transfusion triggers. Transfus Med. 2020;30(2):86-105. doi:10.1111/tme.12667
  26. Terceros-Almanza LJ, García-Fuentes C, Bermejo-Aznárez S, et al. Prediction of massive bleeding in a prehospital setting: validation of six scoring systems. Med Intensiva (Engl Ed). 2019;43(3):131-138. doi:10.1016/j.medin.2017.12.005
  27. Yin G, Radulovic N, O'Neill M, Lightfoot D, Nolan B. Predictors of Transfusion in Trauma and Their Utility in the Prehospital Environment: A Scoping Review. Prehosp Emerg Care. 2023;27(5):575-585. doi:10.1080/10903127.2022.2120935
  28. Guyette FX, Sperry JL, Peitzman AB, et al. Prehospital Blood Product and Crystalloid Resuscitation in the Severely Injured Patient: A Secondary Analysis of the Prehospital Air Medical Plasma Trial. Ann Surg. 2021;273(2):358-364. doi:10.1097/SLA.0000000000003324
  29. Moors XRJ, Bouman SJM, Peters JH, et al. Prehospital Blood Transfusions in Pediatric Patients by a Helicopter Emergency Medical Service. Air Med J. 2018;37(5):321-324. doi:10.1016/j.amj.2018.05.008
  30. Mapp JG, Manifold CA, Garcia AM, Aguilar JL, Stringfellow ML, Winckler CJ. Prehospital blunt traumatic arrest resuscitation augmented by whole blood: a case report. Transfusion. 2020;60(5):1104-1107. doi:10.1111/trf.15740
  31. Sperry JL, Guyette FX, Brown JB, et al. Prehospital Plasma during Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock. N Engl J Med. 2018;379(4):315-326. doi:10.1056/NEJMoa1802345
  32. Gruen DS, Brown JB, Guyette FX, et al. Prehospital plasma is associated with distinct biomarker expression following injury. JCI Insight. 2020;5(8):e135350, 135350. doi:10.1172/jci.insight.135350
  33. Russell RT, Koenig SM. Prehospital Transfusion in Pediatric Trauma-The Clock Is Ticking. JAMA Pediatr. 2023;177(7):663-664. doi:10.1001/jamapediatrics.2023.1297
  34. Prehospital use of plasma in traumatic hemorrhage (The PUPTH Trial): study protocol for a randomised controlled trial - PubMed. Accessed March 7, 2024. https://pubmed.ncbi.nlm.nih.gov/26220293/
  35. Braverman MA, Smith A, Pokorny D, et al. Prehospital whole blood reduces early mortality in patients with hemorrhagic shock. Transfusion. 2021;61 Suppl 1:S15-S21. doi:10.1111/trf.16528
  36. Shlaifer A, Siman-Tov M, Radomislensky I, et al. The impact of prehospital administration of freeze-dried plasma on casualty outcome. J Trauma Acute Care Surg. 2019;86(1):108-115. doi:10.1097/TA.0000000000002094
  37. Braverman MA, Schauer SG, Ciaraglia A, et al. The impact of prehospital whole blood on hemorrhaging trauma patients: A multi-center retrospective study. J Trauma Acute Care Surg. 2023;95(2):191-196. doi:10.1097/TA.0000000000003908
  38. Braverman MA, Smith AA, Ciaraglia AV, et al. The regional whole blood program in San Antonio, TX: A 3-year update on prehospital and in-hospital transfusion practices for traumatic and non-traumatic hemorrhage. Transfusion. 2022;62 Suppl 1:S80-S89. doi:10.1111/trf.16964
  39. Moore EE, Johnson JL, Moore FA, Moore HB. The USA Multicenter Prehosptial Hemoglobin-based Oxygen Carrier Resuscitation Trial: scientific rationale, study design, and results. Crit Care Clin. 2009;25(2):325-356, Table of Contents. doi:10.1016/j.ccc.2009.01.002
  40. Deeb AP, Guyette FX, Daley BJ, et al. Time to early resuscitative intervention association with mortality in trauma patients at risk for hemorrhage. J Trauma Acute Care Surg. 2023;94(4):504-512. doi:10.1097/TA.0000000000003820
  41. Elterman J, Brasel K, Brown S, et al. Transfusion of red blood cells in patients with a prehospital Glasgow Coma Scale score of 8 or less and no evidence of shock is associated with worse outcomes. J Trauma Acute Care Surg. 2013;75(1):8-14; discussion 14. doi:10.1097/TA.0b013e318298492e
  42. Shand S, Curtis K, Dinh M, Burns B. What is the impact of prehospital blood product administration for patients with catastrophic haemorrhage: an integrative review. Injury. 2019;50(2):226-234. doi:10.1016/j.injury.2018.11.049
  43. Shand S, Curtis K, Dinh M, Burns B. What is the impact of prehospital blood product administration for patients with catastrophic haemorrhage: an integrative review. Injury. 2019;50(2):226-234. doi:10.1016/j.injury.2018.11.049
  44. Rangrass G. Whole blood use in trauma resuscitation: targeting prehospital transfusion. Curr Opin Anaesthesiol. 2022;35(2):146-149. doi:10.1097/ACO.0000000000001099

Project Timeline

Prehospital EMS Blood Transfusion

May 23, 2024
Topic Initiated
May 28, 2024
Key Questions
May 28, 2024 - Jun 18, 2024
Page last reviewed May 2024
Page originally created May 2024

Internet Citation: Key Questions: Prehospital EMS Blood Transfusion. Content last reviewed May 2024. Effective Health Care Program, Agency for Healthcare Research and Quality, Rockville, MD.
https://effectivehealthcare.ahrq.gov/products/ems-blood-transfusion

Select to copy citation