How do we provide blood products to trauma patients?

T rauma is the leading cause of death in individuals between the ages of 5 and 45 years worldwide and is expected to become the second leading cause of death by 2020 across all age groups. Nationally, approximately 1 out of every 1000 Americans is hospitalized annually for injuries sustained secondary to trauma, with these patients receiving approximately 10% to 15% of the 14.6 million red blood cell (RBC) units transfused in the United States. Exsanguination is an important cause of mortality for trauma patients, and the successful management of severely injured patients depends in part on adequate and timely transfusion support. Therefore, it is not surprising that the provision of optimal transfusion support for trauma patients has generated much interest and discussion, especially in recent years with newly emerging data from both civilian and military settings. Transfusion support in acute trauma can be challenging and demanding on the resources of the blood bank. The need for large volumes of blood components for some patients, particularly those with the greatest risk of mortality, can arise before or within minutes of their arrival to the hospital. Recent data from one large trauma center in the United States showed that 62% of all RBC units were administered in the first 24 hours of admission, with 18% given uncrossmatched due to the urgency of transfusion. Although the majority (91%) of trauma patients were not transfused, the few (3%) that were massively transfused (i.e., receiving more than 10 units of RBCs) received more than 71% of all RBC units given. Furthermore, this subgroup of patients also had a high mortality rate of 39%. Occasionally, a single patient can require such massive transfusion support that a significant amount of available blood bank resources can be consumed with the patient’s care. For example, at our center, among trauma victims who survived in the past 12 months, the maximum amount of blood products given to a single patient in 1 day was 112 units of RBCs, 70 units of plasma, 40 units of cryoprecipitate, and 6 units of apheresis platelets (PLTs). Such data illustrate that for acute trauma cases, the transfusion service needs to provide large amounts of appropriate blood products quickly and communicate effectively with the clinical team to allow for early recognition of patients with massive transfusion requirements to keep up with their blood product needs. Although there has been much interest recently in what constitutes the optimal transfusion strategy for trauma patients (e.g., role of early plasma transfusion or use of alternative hemostatic agents), there is little information available addressing the logistic issues posed by trauma patients on the transfusion service. All blood banks supporting trauma patients face challenges that include how to minimize delays associated with patient registration and completion of requisition forms, how to provide adequate patient safety measures to avoid misidentification and mistransfusion, how to facilitate effective communication between the blood bank and the clinical team, how to rapidly deliver blood products to patient care locations, and finally, how to remain organized and well coordinated in the fast-moving and stressful environment of trauma care. We present here a description of our trauma transfusion program, which has evolved during the past two to three decades of supporting a Level I trauma center. It is our belief that features of our program, which address the common challenges listed above, can be adapted to suit the unique characteristics of other facilities. We also describe specific aspects of our trauma transfusion program that were identified as areas for improvement after we provided transfusion support to multiple victims from a recent train accident. ABBREVIATIONS: BBID = blood bank identification; ED = emergency department; ID = identification; MRN = medical record number; RR-UCLA = Ronald Reagan UCLA Medical Center.