Improving patient outcomes through clinical studies

To ensure the best outcome for patients, early intervention is essential in cases of major traumatic haemorrhage. Here, Dr Harriet Tucker, Trauma Research and Whole Blood Fellow, and Dr Laura Green, Consultant in Haemostasis and Transfusion Medicine, share the story of a patient who received a combined red blood cell and plasma transfusion from paramedics at the scene of the injury.

The red cell and plasma study was a multicentre cohort study to establish the feasibility of pre-hospital transfusion of a combined red blood cell and plasma product delivered at the roadside to critically injured patients.¹ The study was a collaboration between NHS Blood and Transplant, Barts Health NHS Trust and Queen Mary University of London.

The use of a combined component … can overcome … logistical challenges allowing quicker, earlier delivery of blood products in equal ratios, and the potential to improve survival rates.

The UK standard of care in-hospital for traumatic haemorrhage is early haemostatic resuscitation – delivering a balanced ratio of blood products to the patient as early as possible. Most potentially preventable deaths for people who bleed due to traumatic injury occur in the first three hours of injury, and acute traumatic coagulopathy begins at the point of injury. Trauma-induced coagulopathy (TIC) is a clinical syndrome driven by the combination of shock and tissue injury, resulting in uncontrolled bleeding; management focuses on stopping the bleeding, reversing the shock and preventing worsening TIC by restoring the circulating blood volume.

Most potentially preventable deaths for people who bleed due to traumatic injury occur in the first three hours of injury…

To help reduce these early deaths, which often occur before the patient reaches the hospital, most UK Air Ambulances carry separate bags of red blood cells and plasma. The latter is carried either in the form of pre-thawed fresh frozen plasma (which has a short shelf-life and must be stored cold) or lyophilised plasma (which has a longer shelf life but must be reconstituted prior to use). The use of these separate components in a pre-hospital setting presents storage, resource, logistical and operational challenges. These challenges include a limited number of transfusion sets, limited blood warmers to warm the blood prior to use to prevent hypothermia and prevent worsening of TIC, storage constraints to carry enough bags of each component, and the time taken to ensure safety checks are carried out appropriately for each blood component transfused.

The use of a combined component, such as red cell and plasma, can overcome many of these logistical challenges allowing quicker, earlier delivery of blood products in equal ratios, and the potential to improve survival rates. For example, one bag of combined red cell and plasma is the equivalent of transfusing one bag of red blood cells and one bag of thawed plasma – all of which need to undergo safety checks, be transfused separately and sequentially, through limited intravenous sites.

Alvin’s story

In December 2018, Alvin suffered a stab injury to his right thigh, just above the knee. He lost a lot of blood on scene, and a bystander performed initial first aid by putting pressure on the wound and applying a tourniquet made from rope. The paramedic team then applied three combat application tourniquets to reduce the bleeding.

Alvin’s story highlights the benefits of trialling new products and interventions and constantly striving to improve patient care…

20 minutes after the injury, the London Air Ambulance arrived. Alvin was unwell, displaying signs of shock from significant blood loss. He had a reduced level of consciousness, his heart rate was very fast and his blood pressure was low. In the 22 minutes that the pre-hospital critical care team were on scene, they performed a pre-hospital anaesthetic, gained intravenous access into a large central vein and transfused three bags of red cell and plasma through this single line and through one blood warmer. By only having to transfuse three bags (instead of six separate bags) through one intravenous line, Alvin could be resuscitated rapidly, reducing the time needed for blood transfusion on scene, correcting TIC earlier and allowing the small team to perform other time critical interventions, all of which was paramount to his survival.

Alvin was flown to the Royal London Hospital arriving just 70 minutes after the time of his injury, where he was met by the ‘Code Red’ trauma team. The Code Red team manage patients who are bleeding and who need immediate attention to stop their bleeding and save their lives. He received a blood transfusion in the Emergency Department and was taken directly to the pre-prepared operating theatre. Here, he underwent repair of the blood vessels that had been damaged in his leg and further blood transfusion. Alvin was transferred to the intensive care unit and less than ten days after being admitted, he was discharged home to his family. Alvin was able to move independently and was shortly back to work with support from the hospital’s After Trauma Team.

Alvin’s story highlights the benefits of trialling new products and interventions and constantly striving to improve patient care to give them the best possible opportunity to go home to their families and continue their lives as they would want to.

1. Red cell and plasma study. Available at: https://www.c4ts.qmul.ac.uk/research-programmes/red-cells-and-plasma-transfusion-study