Emergency preparedness for mass casualty events: South Texas commentary on the development of a statewide emergency response system.

Mass casualty incidents (MCIs) are on the rise in the USA, and hemorrhage is the leading cause of preventable death in trauma. The need for rapid access to life-saving blood and blood products is essential for preventing death due to hemorrhage. It is well established that most major cities in the USA are underprepared to meet blood transfusion requirements in the event of an MCI. The South Texas Whole Blood Consortium sought to rectify this and vowed to be prepared to provide low-titer type O-positive whole blood (LTOWB) and blood components to the people who need it, where and when they need it. This system was able to transport 25 units of LTOWB and packed red blood cells almost 100 miles away to Uvalde Memorial Hospital within just 67 minutes after notification of an active shooter. The regional consortium has created a pool of dedicated LTOWB donors affectionately called Heroes in Arms who can be called on to instantly augment locoregional blood supply. Previously pregnant women have historically been excluded from donating plasma and LTOWB due to the increased rates of human leukocyte antigen (HLA) antibody (Ab) positivity, which is associated with transfusion-related acute lung injury. However, the South Texas Blood and Tissue Center in San Antonio had a large number of qualified, previously pregnant females desire to join the Heroes in Arms program prompting them to assess the feasibility of providing HLA Ab testing for this demographic and the results were promising. This is the first report of previously pregnant women being included in the pool for donation of LTOWB.

Walking blood bank: a plan to ensure self-sufficiency in an era of blood shortage.

Mass casualty incidents and massive transfusion requirements continue to plague the USA with hemorrhage remaining the number one cause of death in trauma. The unfortunate reality of numerous mass shootings in Southwest Texas has led to the need for a way in which to provide blood during these events as rapidly as it is required. Multiple agencies within the Southwest Texas system have united to help provide this life-saving blood to people when they need it most. This effort began with the development of a system for safe, efficient, and now widespread use of whole blood in the region. After demonstrating the success of delivering large quantities of blood during the Uvalde shooting, we have begun to develop a walking blood bank that is similar to what the miliary uses on the battlefield. The concept behind this initiative is to have a cohort of whole blood donors who are preselected to join the program which is now dubbed 'Heroes in Arms'. These donors will be called upon to donate whole blood during a massive transfusion event. Their blood will be rapidly screened prior to transfusion to the patient. This blood will still undergo the normal rigorous testing and, should any potentially transmissible diseases by discovered post-transfusion, the individual who received that product will be treated accordingly. Given the low rate of transmissible disease among this preselected population, combined with rapid screening prior to transfusion, the risk of a person receiving a transmissible disease is insignificant in comparison to the benefit of having blood to transfuse during hemorrhage. This model is a promising collaborative effort to provide in a timely and sufficient blood product in cases of major need which will consequently minimize the number of traumatically injured civilian patients who die from hemorrhage.

The impact of prehospital whole blood on hemorrhaging trauma patients: A multi-center retrospective study.

BACKGROUND: Whole blood (WB) use has become increasingly common in trauma centers across the United States for both in-hospital and prehospital resuscitation. We hypothesize that prehospital WB (pWB) use in trauma patients with suspected hemorrhage will result in improved hemodynamic status and reduced in-hospital blood product requirements. METHODS: The institutional trauma registries of two academic level I trauma centers were queried for all patients from 2015-2019 who underwent transfusion upon arrival to the trauma bay. Patients who were dead on arrival or had isolated head injuries were excluded. Demographics, injury and shock characteristics, transfusion requirements, including massive transfusion protocol (MTP) (>10 U in 24 hours) and rapid transfusion (CAT3+) and outcomes were compared between pWB and non-pWB patients. Significantly different demographic, injury characteristics and pWB were included in univariate followed by stepwise logistic regression analysis to determine the relationship with shock index (SI). Our primary objective was to determine the relationship between pWB and improved hemodynamics or reduction in blood product utilization. RESULTS: A total of 171 pWB and 1391 non-pWB patients met inclusion criteria. Prehospital WB patients had a lower median Injury Severity Score (17 vs. 21, p < 0.001) but higher prehospital SI showing greater physiologic disarray. Prehospital WB was associated with improvement in SI (-0.04 vs. 0.05, p = 0.002). Mortality and (LOS) were similar. Prehospital WB patients received fewer packed red blood cells, fresh frozen plasma, and platelets units across their LOS but total units and volumes were similar. Prehospital WB patients had fewer MTPs (22.6% vs. 32.4%, p = 0.01) despite a similar requirement of CAT3+ transfusion upon arrival. CONCLUSION: Prehospital WB administration is associated with a greater improvement in SI and a reduction in MTP. This study is limited by its lack of power to detect a mortality difference. Prospective randomized controlled trials will be required to determine the true impact of pWB on trauma patients. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Use of whole blood deployment programs for mass casualty incidents: South Texas experience in regional response and preparedness.

INTRODUCTION: Firearm-related deaths have become the leading cause of death in adolescents and children. Since the Sutherland Springs, TX mass casualty incident (MCI), the Southwest Texas Regional Advisory Council for trauma instituted a prehospital whole blood (WB) program and blood deployment program for MCIs. METHODS: The program was adopted statewide by the Texas Emergency Medical Task Force, of which Southwest Texas Regional Advisory Council is the lead for Emergency Medical Task Force 8. The recent active shooter MCI in Uvalde, TX was the first time the MCI blood deployment program had been used. To our knowledge, no other similar programs exist in this or any other country. RESULTS: On May 24, 2022, 19 children and 2 adults were killed at an MCI in Uvalde, TX. The MCI WB deployment protocol was initiated, and South Texas Blood and Tissue Center prepared 15 U of low-titer O-positive whole blood and 10 U of leukoreduced O packed cells. The deployed blood arrived at Uvalde Memorial Hospital within 67 minutes. One of the pediatric patients sustained multiple gunshots to the chest and extremities. The child was hypotensive and received 2 U of leukoreduced O packed cells, one at the initial hospital and another during transport. On arrival, the patient required 2 U of low-titer O-positive whole blood and underwent a successful hemorrhage control operation. The remaining blood was returned to South Texas Blood and Tissue Center for distribution. CONCLUSION: Multiple studies have shown the association of early blood product resuscitation and improved mortality, with WB being the ideal resuscitative product for many. The ongoing efforts in South Texas serve as a model for development of similar programs throughout the country to reduce preventable deaths. This event represents the first ever successful deployment of WB to the site of an MCI related to a school shooting in the modern era. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level V.

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.

Low titer type O Rh-D + whole blood (LTO + WB) has become a first-line resuscitation medium for hemorrhagic shock in many centers around the World. Showing early effectiveness on the battlefield, LTO + WB is used in both the pre-hospital and in-hospital settings for traumatic and non-traumatic hemorrhage resuscitation. Starting in 2018, the San Antonio Whole Blood Collaborative has worked to provide LTO + WB across Southwest Texas, initially in the form of remote damage control resuscitation followed by in-hospital trauma resuscitation. This program has since expanded to include pediatric trauma resuscitation, obstetric hemorrhage, females of childbearing potential, and non-traumatic hemorrhage. The objective of this manuscript is to provide a three-year update on the successes and expansion of this system and outline resuscitation challenges in special populations.

Prehospital whole blood reduces early mortality in patients with hemorrhagic shock.

BACKGROUND: Low titer O+ whole blood (LTOWB) is being increasingly used for resuscitation of hemorrhagic shock in military and civilian settings. The objective of this study was to identify the impact of prehospital LTOWB on survival for patients in shock receiving prehospital LTOWB transfusion. STUDY DESIGN AND METHODS: A single institutional trauma registry was queried for patients undergoing prehospital transfusion between 2015 and 2019. Patients were stratified based on prehospital LTOWB transfusion (PHT) or no prehospital transfusion (NT). Outcomes measured included emergency department (ED), 6-h and hospital mortality, change in shock index (SI), and incidence of massive transfusion. Statistical analyses were performed. RESULTS: A total of 538 patients met inclusion criteria. Patients undergoing PHT had worse shock physiology (median SI 1.25 vs. 0.95, p < .001) with greater reversal of shock upon arrival (-0.28 vs. -0.002, p < .001). In a propensity-matched group of 214 patients with prehospital shock, 58 patients underwent PHT and 156 did not. Demographics were similar between the groups. Mean improvement in SI between scene and ED was greatest for patients in the PHT group with a lower trauma bay mortality (0% vs. 7%, p = .04). No survival benefit for patients in prehospital cardiac arrest receiving LTOWB was found (p > .05). DISCUSSION: This study demonstrated that trauma patients who received prehospital LTOWB transfusion had a greater improvement in SI and a reduction in early mortality. Patient with prehospital cardiac arrest did not have an improvement in survival. These findings support LTOWB use in the prehospital setting. Further multi-institutional prospective studies are needed.

Operationalizing the Deployment of Low-Titer O-Positive Whole Blood Within a Regional Trauma System.

INTRODUCTION: The implementation of a low-titer O+ whole blood (LTOWB) resuscitation algorithm, particularly in the prehospital environment, has several inherent challenges, including cost, limited and inconsistent supply, and the logistics of cold-chain management. The Southwest Texas Regional Advisory Council has implemented the nation's first multidisciplinary, multi-institutional regional LTOWB program. This research effort was to illustrate the successful deployment of LTOWB within a regional trauma system. MATERIALS AND METHODS: A deliberate systems approach to the deployment of LTOWB was used. Tenets of this program included the active management of blood donor sources and blood supply levels to minimize wastage as a result of expiration, maximize product utilization, the use of prehospital transfusion triggers, and efforts to decrease program costs prehospital agencies. A novel LTOWB rotation system was established using the concept of a "rotation site" and "rotation center." Standardized transfusion criteria, a regional approved equipment list, a regional Prehospital Blood Product Transfusion Record, and a robust multilevel communication plan serves as the framework for the program. The San Antonio Whole Blood Consortium was developed to create a consensus driven forum to manage and guide the program. RESULTS: From January 2018 to October 2019, LTOWB has been placed at 18 helicopter emergency medical services (HEMS) bases, 12 ground emergency medical service (EMS) agencies, 1 level I trauma center, and 1 level IV trauma center. A total of 450 patients have received a prehospital LTOWB transfusion. Program wide, the wastage rate of LTOWB due to expiration is between 1% and 2%. No complications related to prehospital LTOWB administration have been identified. DISCUSSION: This work demonstrates a novel model for the development of a trauma system LTOWB program. The program's implementation augments remote damage control resuscitation strategies and requires the integration and collaboration of a multidisciplinary stakeholder team to optimize efficiency, performance, and safety of the program.

From battlefront to homefront: creation of a civilian walking blood bank.

Hemorrhagic shock remains the leading cause of preventable death on the battlefield, despite major advances in trauma care. Early initiation of balanced resuscitation has been shown to decrease mortality in the hemorrhaging patient. To address transfusion limitations in austere environments or in the event of multiple casualties, walking blood banks have been used in the combat setting with great success. Leveraging the success of the region-wide whole blood program in San Antonio, Texas, we report a novel plan that represents a model response to mass casualty incidents.

Give the trauma patient what they bleed, when and where they need it: establishing a comprehensive regional system of resuscitation based on patient need utilizing cold-stored, low-titer O+ whole blood.

BACKGROUND: Despite countless advancements in trauma care a survivability gap still exists in the prehospital setting. Military studies clearly identify hemorrhage as the leading cause of potentially survivable prehospital death. Shifting resuscitation from the hospital to the point of injury has shown great promise in decreasing mortality among the severely injured. MATERIALS AND METHODS: Our regional trauma network (Southwest Texas Regional Advisory Council) developed and implemented a multiphased approach toward facilitating remote damage control resuscitation. This approach required placing low-titer O+ whole blood (LTO+ WB) at helicopter emergency medical service bases, transitioning hospital-based trauma resuscitation from component therapy to the use of whole blood, modifying select ground-based units to carry and administer whole blood at the scene of an accident, and altering the practices of our blood bank to support our new initiative. In addition, we had to provide information and training to an entire large urban emergency medical system regarding changes in policy. RESULTS: Through a thorough, structured program we were able to successfully implement point-of-injury resuscitation with LTO+ WB. Preliminary evaluation of our first 25 patients has shown a marked decrease in mortality compared to our historic rate using component therapy or crystalloid solutions. Additionally, we have had zero transfusion reactions or seroconversions. CONCLUSION: Transfusion at the scene within minutes of injury has the potential to save lives. As our utilization expands to our outlying network we expect to see a continued decrease in mortality among significantly injured trauma patients.

Prehospital low-titer cold-stored whole blood: Philosophy for ubiquitous utilization of O-positive product for emergency use in hemorrhage due to injury.

The mortality from hemorrhage in trauma patients remains high. Early balanced resuscitation improves survival. These truths, balanced with the availability of local resources and our goals for positive regional impact, were the foundation for the development of our prehospital whole blood initiative-using low-titer cold-stored O RhD-positive whole blood. The main concern with use of RhD-positive blood is the potential development of isoimmunization in RhD-negative patients. We used our retrospective massive transfusion protocol (MTP) data to analyze the anticipated risk of this change in practice. In 30 months, of 124 total MTP patients, only one female of childbearing age that received an MTP was RhD-negative. With the risk of isoimmunization very low and the benefit of increased resources for the early administration of balanced resuscitation high, we determined that the utilization of low-titer cold-stored O RhD-positive whole blood would be safe and best serve our community.

Analysis of remote trauma transfers in South Central Texas with comparison with current US combat operations: results of the RemTORN-I study.

BACKGROUND: This study aimed to analyze demographic, epidemiologic, temporal, and outcome data from an integrated trauma registry of patients undergoing initial stabilization and transfer within a mature domestic trauma network; compare data with a companion subset from the Department of Defense Trauma Registry. Texas Trauma Service Area-P is composed of 25 counties, 15 rural Level IV trauma centers (no acute care surgery), and two Level I trauma centers. METHODS: This study has a retrospective cohort design. We hypothesize that Injury Severity Scores (ISSs), time intervals, and other clinical indicators would be complimentary to contemporary combat casualties. Inclusion criteria include age 18 years to 80 years, transferred from Level IV to Level I trauma center, or expired en route. RESULTS: A total of 543 subjects (84%) met the criteria and were analyzed. Averages and confidence intervals were as follows: age of 40 years (38-41 years), males at 81%, ISS of 10 (10-11), intensive care unit stay of 2 days (1-3 days), and hospital stay of 5 days (4-6 days). Mechanisms of injury were as follows: penetrating (15%), blunt weapon (19%), stabs (9%), burns (5%), and gunshots (5%). Eight percent received blood within the first 24 hours. Survival was at 98%. Time intervals (95% confidence interval) were as follows: prehospital at 1:43 (1:29-1:58), Level IV dwell time at 3:17 (3:06-3:28), interfacility transfer at 1:43 (1:36-1:49), and total at 6:39 (6:20-6:58). RemTORN cases were older, spent longer time en route to Level I, and had ISS similar to combat casualties. Rates of blood transfusion in the first 24 hours and survival were similar in order of magnitude. CONCLUSION: The RemTORN platform is operational. Demographic, epidemiologic, and temporal characteristics as observed will support clinical investigations of traumatic coagulopathy, shock, and potential interventions before Level I arrival. Results of such investigations will likely be applicable to the contemporary and future battlefield.

Personal identity verification for regional emergency workers.

South Central Texas emergency planners have organised a regional Personal Identity Verification (PIV) project for hospital and emergency workers. This paper describes the development and administrative challenges in designing and implementing an electronic PIV system across multiple organisations in a 22-county region.

A regional medical operations center improves disaster response and inter-hospital trauma transfers.

BACKGROUND: Delays in both inter-hospital trauma transfers and disaster response are common. We hypothesized patient flow could be improved by formal adoption of systems that improve cooperation and communication. METHODS: The regional trauma database of the Southwest Texas Regional Advisory Council for Trauma and the Regional Medical Operations Center (RMOC) database were queried to test the hypothesis. RESULTS: A total of 9507 trauma patients were transferred. Medcom resulted in decreased transfer process times. The RMOC was activated during Hurricanes Katrina and Rita. During two 24-hour periods, the RMOC coordinated the inter-hospital transfer of 781 patients and the movement of thousands of evacuees and special needs patients. CONCLUSIONS: Medcom, an organized system combining a communications center with formal trauma center cooperation, improves patient flow and reduces trauma transfer times. The RMOC, based on the same principles of cooperation and communication, allows for rapid transfer of hospitalized and special needs patients during disaster/mass casualty situations.