Episode 217: Prehospital Blood Transfusion

We discuss the shift to prehospital blood to treat shock sooner.

Hosts:

Nichole Bosson, MD, MPH, FACEP

Avir Mitra, MD

https://media.blubrry.com/coreem/content.blubrry.com/coreem/Prehospital_Transfusion.mp3

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Tags: EMS, Prehospital Care, Trauma

Show Notes

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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

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