Services( OEMS) became the first entity in the United States to publish a statewide whole blood protocol in April 2024 where it was formally published in the July 2024 protocol update.
Currently, the program requires strict compliance with the WV Department of Health EMS guideline GL022 which outlines the required equipment for participation. The products must be maintained in a Pelican Credo Series Four 2-liter cooler with use of a digital thermometer and liquid-inglass Celsius thermometer. The blood is exchanged every 7 days to maintain fresh product and ensure this resource is utilized in the most efficient way possible.
In accordance with policies set forth by the Association for the Advancement of Blood and Biotherapies, prehospital blood is maintained between 1 ° C and 60 ° C. Blood product temperature must be documented at least every 4 hours. The temperature is monitored constantly with real time alerts using the TempStick Sensor as sold by Ideal Sciences, a company based in Utah. This Wi-Fi connected sensor maintains constant communication with the registered smart device. Additionally, all products provided by WVU Medicine Transfusion Service / Blood Bank are monitored using a temperature indicator sticker attached to the unit which will indicate if the temperature exceeds the acceptable transport temperature range( 1 ° C-100 ° C).
Equipment required for administration includes the QinFlow Warrior Lite Blood Warming System coupled to any generic Y type filtered blood tubing. Optional equipment for administration includes the Life- Flow PLUS hand-operated rapid infuser. The current total startup cost to participate in this program, without purchasing the blood products directly, is around $ 10,000. This is a large sum of money for any EMS system to invest. While it is technically permissible for every 911 EMS transport agency in WV to participate in the pre-hospital blood program, many limitations exist in addition to the start-up cost. These include provider requirements, access to a supportive supplier of required blood products, deployment models to cover large geographical areas, and the low frequency of patients meeting transfusion criteria in
lesser populated areas of the state. Combining these factors, few WV agencies are reasonably poised to take on the added cost and operational burden associated with participation.
Providers wishing to participate in this WV OEMS- and agency-approved blood program must complete the required training course conducted by a critical care paramedic who has completed the course and holds a valid WV state instructor certification with at least five prehospital blood transfusions. The training also includes education about transfusion reactions and other complications and treatment pathways. Monitoring of temperature changes, pain, vital instability, and allergic signs is crucial. Protocols are already in place for corresponding reactions( i. e. anaphylaxis). The endorsement requires annual renewal. WV OEMS proctors and grades the exam. Administration of blood products in the 911 setting requires the presence of two ALS providers who hold a valid and current WV OEMS blood endorsement. At the time of authorship of this article, all ALS providers at HCES have been endorsed by WV OEMS.
In traumatic hemorrhage, 1:1:1 transfusion protocols( balancing the transfusion of platelets, red blood cells, and plasma in a 1:1:1 ratio) have been considered standard of care to reduce mortality from exsanguination. 1 While early blood transfusion in hemorrhagic trauma patients has been a cornerstone of care, LTOWB is becoming increasingly common with benefit in transport and storage of one product opposed to storage, maintenance, and transfusion of multiple blood components. Data from the American College of Surgeons Trauma Quality Improvement Program databank suggests that earlier ED administration of whole blood in patients with severe hemorrhage has an associated survival benefit. 2 Resuscitation with LTOWB in trauma has been shown to reduce activation of mass transfusion protocols( MTPs), and appears to be generally safe as compared to component therapy with mortality benefit starting at 4 hours to 28 days in traumatic patients with worse prehospital prognostics. 3, 4
Patients with nontraumatic and traumatic hemorrhage have variable presentations and may be appropriate for whole blood administration in the prehospital setting. 5 – 7 Nontraumatic prehospital LTOWB administration has been documented previously in obstetric bleeding as well. 8, 9 Further research in the efficacy of LTOWB and subsequent mortality / morbidity benefits in nontraumatic hemorrhage is needed for both adult and pediatric populations. 10 It is likely that more remote areas will benefit further from this life saving resource than those in closer proximity to hospitals who are able to provide higher volume transfusions and definitive surgical care.
Access to LTOWB can be limited in certain settings depending on supply and storage requirements of whole blood products. 11 Prehospital administration of LTOWB does not account for patients with antibodies who may be at risk for transfusion reactions; however, the use of LTOWB is widely considered to be safe and effective. WV protocol requires close monitoring for transfusion-related complications as outlined in WVOEMS GL022. If a reaction is suspected, the transfusion and tubing must be discontinued and secured for testing and IV normal saline is to be infused through this IV. Treatment and documentation of signs and symptoms as well as receiving provider notification are required by protocol. Weighing the risks and benefits, patients meeting criteria for hemorrhagic shock with evidence of blood loss have shown repeated benefit in mortality and morbidity with timely blood product transfusion. The prehospital administration of LTOWB likely should continue to be explored and utilized with standardized protocols for both 911 ground EMS systems as well as critical care air transport. 12
CONCLUSION
Our patient was able to ambulate independently out of the hospital of his own volition despite having received significant medical resuscitation aided in large part by rapid improvement in every observable metric of perfusion following prehospital whole blood transfusion. This first documented case of nontraumatic whole blood administration in the prehospital setting by a 911 EMS agency in WV highlights the opportunity for EMS systems to adopt and implement this potentially lifesaving intervention in appropriate cases of hemorrhagic shock.
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