One thing about prehospital care–you never know where and when you’ll have to respond. That’s certainly the case for the flight crew members who were called after a patient was crushed between 400-plus pound pipes at work.
While this case sounds unique, traumatic injuries are not—tragically, they kill hundreds of people every day in the United States. And many of those patients’ lives could be saved if they received faster care, especially those whose deaths are caused by hemorrhage, one of the leading causes of death from trauma.1 Quick recognition of the injury and bystander and first responder use of direct pressure and tourniquets, along with rapid transport to a trauma center, are known to make an impact on outcomes.2 And drugs like tranexamic acid (TXA) seem to help as well, though more research on its use in the prehospital setting is needed.3
But what if the patient lost a significant amount of blood volume before the bleeding could be stopped? In some cases, unless the patient is already in the hospital, it might be too late. Even just a short period without adequate perfusion can be deadly. That’s why more and more prehospital services are carrying blood products and transfusing patients even before they arrive in the trauma bay.
And early data show it’s working. A recently published study by Broome et al. indicated that mortality was lower in a group of patients who received an advanced resuscitative care bundle from paramedics in the field than in a group of similar patients who did not.4 The bundle, administered by New Orleans EMS, included calcium, TXA, and packed red blood cells, given through the LifeFlow PLUS rapid infuser.
Case Presentation & Challenges
A 20-year-old male was at work when a large pipe fell, crushing him and a co-worker. Initial responders found him awake and alert but with severe injuries to both legs. The EMS crews acted quickly, placing a tourniquet to stop major bleeding from an open fracture in one leg, and splinting the other leg. Recognizing signs of shock and the severity of the injuries, they also quickly called for a helicopter to transport the patient more than 50 miles to the trauma center.
When the flight crew from Ochsner arrived, Chief Flight Nurse Mark McCormick found the patient in the ambulance, still showing signs of poor perfusion after the ground crew had administered a bolus of normal saline. External bleeding was controlled, but the patient had lost an unknown amount of blood, and it was unclear if he had any other internal injuries. His blood pressure was 90/58 and heart rate 128, with pale, cool skin.
Management
Fortunately for this patient, Ochsner carries blood on its helicopters. McCormick and the other responders quickly decided to administer packed red blood cells (PRBCs), knowing that with a nearly 20-minute flight time, it would be at least a half-hour before the hospital would be able to transfuse the patient. With an 18 ga peripheral IV established, the crew used the LifeFlow PLUS rapid infuser and QinFlow warmer to give the patient 350 mL of PRBCs over just two minutes while en route to the trauma center.
Three minutes after the transfusion, the patient’s vital signs had improved, with a BP of 118/74 and heart rate of 90. The crew also administered fentanyl to control his pain. Ultimately the patient survived to be admitted to the hospital for further treatment.
Discussion
With hemorrhage being a leading cause of death from traumatic injuries, the ability to more rapidly stop bleeding and replace blood volume is critical to saving more lives. The addition of blood products to many flight and ground emergency medical services’ arsenals is in its early stages but already beginning to show a benefit. Improving a patient’s perfusion and mental status may also make a clinician feel more comfortable administering pain medication, as the crew did for this patient.
Carrying blood is only as effective as the equipment to help administer it, though. With the space and weight limits inherent in flight medicine, the portability and ease of use of QinFlow and LifeFlow PLUS allow Ochsner’s crews to not only give blood, but to make sure it is given quickly at appropriate volumes—and without worsening hypothermia, a major contributor to coagulopathy and poor outcomes.5,6
“This is an early use case for us that has demonstrated directly to our staff what LifeFlow can do to save a patient. We’ve organized our entire resuscitation workflow around being able to land directly on the scene and get a unit of blood in a patient in under 3 minutes. LifeFlow is a product showing excellent results in real situations for us and I appreciate their support,” said McCormick.
- Callcut RA, Kornblith LZ, Conroy AS, Robles AJ, Meizoso JP, Namias N, Meyer DE, Haymaker A, Truitt MS, Agrawal V, Haan JM, Lightwine KL, Porter JM, San Roman JL, Biffl WL, Hayashi MS, Sise MJ, Badiee J, Recinos G, Inaba K, Schroeppel TJ, Callaghan E, Dunn JA, Godin S, McIntyre RC Jr, Peltz ED, OʼNeill PJ, Diven CF, Scifres AM, Switzer EE, West MA, Storrs S, Cullinane DC, Cordova JF, Moore EE, Moore HB, Privette AR, Eriksson EA, Cohen MJ; Western Trauma Association Multicenter Study Group. The why and how our trauma patients die: A prospective Multicenter Western Trauma Association study. Journal of Trauma and Acute Care Surgery. 2019;86(5):864-870.
- Berry C, Gallagher JM, Goodloe JM, Dorlac WC, Dodd J, Fischer PE. Prehospital hemorrhage control and treatment by clinicians: a joint position statement. Prehospital Emergency Care. 2023;27(5):544-551.
- Almuwallad A, Cole E, Ross J, Perkins Z, Davenport R. The impact of prehospital TXA on mortality among bleeding trauma patients: A systematic review and meta-analysis. Journal of Trauma and Acute Care Surgery. 2021;90(5):901-907.
- Broome J, Nordham KD, Piehl M, Tatum D, Caputo S, Belding C, De Maio VJ, Taghavi S, Jackson-Weaver O, Harris C, McGrew P, Smith A, Nichols E, Dransfield T, Rayburn D, Marino M, Avegno J, Duchesne J. Faster refill in an urban EMS system saves lives: a prospective preliminary evaluation of a prehospital advanced resuscitative care bundle. Journal of Trauma and Acute Care Surgery. 2024: 10.1097/TA.0000000000004239.
- Boyan CP, Howland WS. Blood temperature: a critical factor in massive transfusion. Anesthesiology. 1961;22:559–563.
- Lier H, Krep H, Schroeder S, Stuber F. Preconditions of hemostasis in trauma: a review. The influence of acidosis, hypocalcemia, anemia, and hypothermia on functional hemostasis in trauma. Journal of Trauma: Injury, Infection, and Critical Care. 2008;65(4):951-960.