Recent developments in military transfusion practice and their impact on civilian healthcare

Introduction. Massive haemorrhage is the leading cause of preventable death following trauma. The mortality rate is high unless actively managed from Point of Injury (POI). However, during the last decade advances in military medicine, including transfusion support, appear to have delivered extraordinary survival advantages. A new transfusion policy was introduced in 2007 in response to the emerging analysis of combat experience underpinned by a revised understanding of the pathophysiology of trauma. Transfusion support was redesigned as part of Damage Control Resuscitation (DCR) to mitigate Trauma Induced Coagulopathy. The Massive Transfusion Capability was an ambitious programme designed to provide transfusion support throughout the continuum of care. The success has led to transfusion support being considered in military and civilian environments where there is a risk of haemorrhage but there is minimal medical infrastructure. Developments such as: a more portable cold chain; whole blood and lyophilised products offered Remote Damage Control Resuscitation (RDCR) whilst addressing the logistic tail. The delivery of the military capability has required considerable innovation during an era in which transfusion practice became subject to an increase in legislative and regulatory measures. The overall objective of this study is to evaluate the recent developments in military transfusion practice and to assess the impact on civilian practice. Methods. The study describes the developments in military transfusion support in a linear sequence from 2006 to 2016. The adoption of military principles and practice is then explored in the context of civilian practice and national emergency transfusion preparedness for Mass Casualty Events (MCE). The source material thesis is derived from the author’s military and civilian, professional and academic practice. The thesis submission is structured around four aims; two military thematic areas which are the recent changes in UK military blood transfusion practice and the development of prehospital transfusion. These are followed by two civilian themes; the introduction of Massive Transfusion Protocols (MTPs) and transfusion planning for Mass Casualty Events (MCEs). The military data has been extracted from the UK Joint Theatre Trauma Registry complimented by quality management systems. The civilian data is derived from the relevant Trauma Registries, Patient Administration Systems and Laboratory Information Management Systems. Descriptive statistics were used to summarize the number of components by year, speciality and patient demographics. Statistical analysis was performed using a variety of software tools. Results. The paradigm of military transfusion has changed in the last decade. The developments have been credited with contributing to survival of the critically injured. Survival is the product of the entire system of care, which – in this setting of combat, incorporates the early external haemorrhage control, hybrid resuscitation; rapid and physician-led recovery from the battlefield, damage control surgery, transfusion support and expert critical care. It is thus not possible to ascertain the individual contribution of transfusion however it has been an important element. Transfusion support is increasingly being considered in at risk environments with minimal infrastructure and logistic support. The collection of Whole blood from a pre-tested Emergency Donor panel is a viable transfusion management option. Knowledge sharing from the Bergen based Blood Far Forward program has enabled the further development of UK military practice. In addition, the concept of the safe universal whole blood donor has informed the wider transfusion community leading to the acceptance of group O Low titre as a new standard. Massive Transfusion Protocols (MTP) have been successfully introduced into civilian practice for both trauma and other causes of massive haemorrhage. Massive Transfusion (MT) is a phenomenon of surgery not trauma and the organisational principles can be applied to all causes of haemorrhage. MT is resource intensive and has implications for both hospital and blood service organisation. However, the civilian studies have not demonstrated a survival advantage and the definitions of MT require standardisation to allow comparison of practice and the design of further studies. The pattern of blood use in civilian Mass Casualty Events differs from that seen in the recent military experience in Afghanistan and Iraq. Far fewer injured require blood and few require Massive Transfusion and haemostatic component support. However, military style planning has added value to the preparation for MCEs and the response to Major Incidents. Elements of military planning have included the optimisation of pre-hospital care, haemorrhage control, transfusion triage, MTPs and emergency donor management. Transfusion Emergency Preparedness should become an integrated part of healthcare emergency planning. Conclusions. Transfusion has emerged as an essential and successful element of modern combat care. The success must be placed in the context of the whole healthcare system, especially pre-hospital care. The nature of military and civilian trauma differs however, many of the recent lessons identified have been intelligently applied to civilian hospital healthcare. Military practice has also informed both pre-hospital emergency care, blood component development and transfusion planning for MCEs. In turn, combat care has benefitted from civilian transfusion governance and regulatory expertise. The continued military-civilian collaboration and innovation in transfusion practice has the potential to benefit not only the military, but also the wider healthcare community

Pre-hospital blood product resuscitation for trauma:a systematic review

INTRODUCTION: Administration of high ratios of plasma to packed red blood cells is a routine practice for in-hospital trauma resuscitation. Military and civilian emergency teams are increasingly carrying prehospital blood products (PHBP) for trauma resuscitation. This study systematically reviewed the clinical literature to determine the extent to which the available evidence supports this practice. METHODS: Bibliographic databases and other sources were searched to July 2015 using keywords and index terms related to the intervention, setting, and condition. Standard systematic review methodology aimed at minimizing bias was used for study selection, data extraction, and quality assessment (protocol registration PROSPERO: CRD42014013794). Synthesis was mainly narrative with random effects model meta-analysis limited to mortality outcomes. RESULTS: No prospective comparative or randomized studies were identified. Sixteen case series and 11 comparative studies were included in the review. Seven studies included mixed populations of trauma and non-trauma patients. Twenty-five of 27 studies provided only very low quality evidence. No association between PHBP and survival was found (OR for mortality: 1.29, 95% CI: 0.84–1.96, P = 0.24). A single study showed improved survival in the first 24 h. No consistent physiological or biochemical benefit was identified, nor was there evidence of reduced in-hospital transfusion requirements. Transfusion reactions were rare, suggesting the short-term safety of PHBP administration. CONCLUSIONS: While PHBP resuscitation appears logical, the clinical literature is limited, provides only poor quality evidence, and does not demonstrate improved outcomes. No conclusions as to efficacy can be drawn. The results of randomized controlled trials are awaited

Fresh Whole Blood Transfusions: Efficacy, Limitations, and the Future

Background: Loss of blood from traumas suffered on the battlefield is the most common cause of death among potentially treatable injuries in frontline military operations (Keenan and Riesberg 2017). Cessation of blood loss and fluid repletion have been major driving factors that can reduce battlefield casualties. Once the hemorrhage has been stopped, the next step is to replace lost volume to decrease cardiac failure or shock (Eastridge et al. 2012; Butler 2017). Uncontrolled hemorrhage can lead to the "trauma triad of death", which consists of hypothermia, acidosis, and impaired coagulation (Howard et al. 2017). Hemostatic resuscitation involves the blood components resembling whole blood. The goals are to avoid metabolic acidosis, hypothermia, treating coagulopathy and stabilizing the patient as soon as possible (Nickson n.d.). The resuscitation fluids of choice for casualties in hemorrhagic shock, listed from most to least preferred are: whole blood; plasma, RBCs and platelets in 1:1:1 ratio; plasma and RBCs in 1:1 ratio; plasma or RBCs alone, and crystalloid fluids (Nickson n.d.). Between October 2001 and June 2011, 4,596 battlefield fatalities were analyzed. Non-compressible hemorrhage is the cause of over 2/3 of battlefield deaths, which makes hemorrhages the leading cause of potentially survivable deaths in combat (Keenan and Riesberg 2017). The major body region bleeding focus accounting for mortality were torso 48%, extremities 31%, and neck/groin/ axilla region 21% (Eastridge et al. 2012). Casualties with severe hemorrhagic injury, the odds of KIA mortality were 83% lower for casualties who needed and received pre-hospital blood transfusion (Shackelford et al. 2017). Evaluating the influences on mortality is helpful for planning efforts that optimize placement, proximity, and provision of timely and effective transport and treatment capabilities to minimize casualty risk (Malsby et al. 2013). Combat wounded on today’s battlefield experience the highest survival rate in history. Advances in battlefield medicine during the conflicts in Iraq and Afghanistan have included the effective use of tourniquets, damage control resuscitation, trauma system development, en route care, use of tranexamic acid, and advanced topical hemostatic dressings (Malsby et al. 2013). In 2008, there was a mandate that all the injured personnel evacuation to surgeon must occur in less than 60 minutes, “The Golden Hour”, that contributed to the lowest mortality rate of any conflict in history (Keenan and Riesberg 2017). Component therapy remains the mainstay in trauma resuscitation. In prolonged field care, access to packed red blood cells, platelets, and fresh frozen plasma is often limited (Keenan and Riesberg 2017). Transfusion of fresh whole blood has been used when access to CT in these settings are limited or have been fully utilized . The process of separating and reconstituting blood can lessen its effectiveness. Current Prolonged Field Care standards identified that the best practice for transfusions would be to maintain a stock of pRBC and FFP and have type-specific donors identified for immediate FWB draw (Keenan and Riesberg 2017). PICOT​ ​Question:​ ​What​ ​are​ ​the​ ​limitations​ ​of​ ​Fresh​ ​Whole​ ​Blood​ ​transfusions​ ​or administration​ ​of​ ​blood​ ​products​ ​in​ ​prolonged​ ​point​ ​of​ ​injury​ ​care​ ​on​ ​the​ ​battlefield?Master of Health Scienc

Whole blood in prehospital damage control resuscitation : -Safety, feasibility, and logistics

Bakgrunn De siste tiårene har det vært et paradigmeskifte i behandlingen av blødningsjokk. Skadebegrensende resuscitering har som hensikt å understøtte hemostatisk evne hos pasienten og reversere og dempe konsekvensene av sjokk slik at pasienten har tilstrekkelige fysiologiske reserver til å overleve påfølgende behandling i sykehus. Strategien baserer seg i all hovedsak på å starte tidlig behandling med blod og blodprodukter. I økende grad har sivile og militære prehospitale tjenester vurdert fullblod som et alternativ for den intiale resusciteringen av blødningsjokk. Selv om fullblod har tiltalende egenskaper er det flere utfordringer ved implementering av fullblod i et prehospitalt system. Forhold knyttet til sikkerhet, logistikk, lagring og praktisk bruk bør evalueres. Mål Å undersøke og evaluere implementeringen av et program for implementering av prehospitalt lavtiter gruppe O fullblod (LTOWB). Metode Paper I undersøkte gjennomførbarhet, sikkerheten og effektivitet av intraossøs sternal autolog re-infusjon av varmt friskt fullblod (WFWB) i en prospektiv human komparativ studie. Paper II undersøkte ex vivo kvaliteten til lav titer type O fullblod (LTOWB) under fremskutt lagring i opptil 21 dager i en lufttett temperaturregulert beholder ved en luftambulansebase sammenlignet med LTOWB lagret i blodbanken. Paper III identifiserte nåværende prehospitale blodtransfusjonsprogrammer, fremtidige behov og potensielle barriærer for implementering av LTOWB i en spørreundersøkelse blant medisinsk ansvarligeleger ved luft og redningshelikoptertjenestene i Norge. Paper IV beskrev implementeringen av et LTOWB-transfusjonsprogram i Luftambulansetjenesten i Bergen i perioden 2015-2020 i en prospektiv observasjonsstudie. Resultater Det var ingen hemolyse etter sternal intraossøs re-infusjon av fullblod. Median infusjonshastighet var 46,2 ml/min for FAST-1-IO nålen, og feilraten ved innleggelse av IO tilgangen for uerfarent personell var 9 %. Fremskutt lagring av LTOWB opptil 21 dager førte ikke til konsekvenser som kan true pasientsikkerheten. Blodet tilfredstilte EU krav i hele lagringsperioden. Det var ingen signifikante forskjeller i de hematologiske variablene, blodplateaggregering eller viskoelastiske egenskaper mellom blod lagret fremskutt og blod lagret i blodbanken. Alle luft og redningshelikopter i Norge har blodprodukter tilgjengelig. Fire av 20 (20 %) har implementert LTOWB. Et flertall av tjenestene har en preferanse for LTOWB siden dette muliggjør tidlig balansert transfusjon og kan ha logistiske fordeler i tidskritiske situasjoner. Blodbanker som leverer LTOWB rapporterer gunstige erfaringer. I løpet av 2015-2020 responderte Luftambulansen i Bergen til 5124 pasienter. Syttito (1,4%) mottok blodtransfusjon. 52 pasientene samtykket til deltagelse i studien. Av disse fikk 48 LTOWB. Førtiseks (88 %) ble innlagt på sykehuset i live, og 76 % av disse fikk ytterligere transfusjoner i løpet av de første 24 timene. De fleste pasienter presenterte med stump skademekanikk (69 %), etterfulgt av blødninger som ikke var relatert til traumer (29 %). Totalt overlevde 36 (69%) 24 timer, og 28 (54%) overlevde 30 dager. Ingen transfusjonsreaksjoner eller logistiske problemer ble rapportert. Konklusjon Intraossøs infusjon av WFWB er trygt, pålitelig og gir tilstrekkelig flow for den initielle resuscitering ved blødningsjokk. Fremskutt lagring av LTOWB i Luftambulansetjenesten er gjennomførbart og trygt. Kvalitet tilfredstiller EU krav opptil 21 dagers lagring, og hemostatiske egenskaper e LTOWB sammenlingbar med LTOWB lagret i blodbanken. Luftambulansetjenestene og blodbankene som leverer LTOWB har gode erfaringer med implementering av LTOWB. Våre undersøkelser viser at implementering av et prehospitalt transfusjonsprogram med fullblod er mulig og sikkert. Det er videre behov for studier som ser på effektiviteten av fullblod sammenlignet med blodkomponenter.Background In the last two decades, resuscitation of hemorrhagic shock has undergone a paradigm shift. Modern damage control resuscitation strategies aim to improve outcomes by facilitating early hemostatic resuscitation with blood and blood products. The ultimate goal is to prevent, reverse or mitigate the severity and duration of shock and its consequences until definitive hemorrhage control can be achieved. As a result, both civilian and military EMS systems are considering whole blood for prehospital resuscitation of hemorrhagic shock. Although appealing, establishing a robust system for forward resuscitation with whole blood is challenging as several vital factors regarding safety, logistics, and implementation barriers need to be considered. Aim To investigate and evaluate the implementation of a pre-hospital low titer group O whole blood (LTOWB) transfusion program. Methods Paper I investigated the feasibility, safety, and efficacy of autologous re-infusion of warm fresh whole blood (WFWB) through an intraosseous sternal device in a prospective human comparative study. Paper II investigated the ex vivo quality of LTOWB during storage for up to 21 days in an airtight thermal container at a helicopter emergency medical system (HEMS) base compared to LTOWB stored in the blood bank. Paper III identified current pre-hospital blood transfusion programs, future needs, and potential obstacles in implementing LTOWB in a national survey among the medical directors of the Norwegian HEMS and Search and Rescue (SAR) helicopter bases. Finally, in a prospective observational study, paper IV described and evaluated the implementation of a LTOWB program in one of the Norwegian HEMS services in 2015-2020. Results There was no evidence of hemolysis following sternal intraosseous re-infusion of whole blood. The median infusion rate was 46.2mL/min for the FAST-1 device, and the failure rate for inexperienced personnel was 9%. Storage of LTOWB complied with the EU regulations throughout remote and in- hospital storage for 21 days. In addition, there were no significant differences in hematology variables, platelet aggregation, or viscoelastic properties between blood stored remotely and in the blood bank. All HEMS and SAR helicopter services in Norway carry LTOWB or blood components. A majority of services have a preference for LTOWB because LTOWB enables early balanced transfusion and may have logistical benefits in time-critical emergencies. This far, four of 20 (20%) have implemented LTOWB. Blood banks and services that provide LTOWB report favorable experiences. During the five years, the Bergen HEMS in study IV responded to 5124 patients. Seventy-two (1.4%) were transfused. Twenty patients were excluded mainly due to a lack of informed consent. Of the 52 patients, 48 received LTOWB. Forty-six (88%) were admitted to the hospital alive, and 76% of these received additional transfusions during the first 24 hours. Most patients presented with blunt trauma mechanisms (69%), followed by hemorrhage unrelated to trauma (29%). Overall 36 (69%) survived 24 hours, and 28 (54%) survived 30 days. No suspected transfusion reactions or logistical issues were reported. Conclusion WFWB transfusion through the IO route is safe, reliable, and provides sufficient flow for the initial resuscitation of hemorrhagic shock. Storage of LTOWB in thermal containers in a pre-hospital HEMS service is feasible and safe. Hemostatic properties are present for up to 21 days of storage and are similar to LTOWB stored in the blood bank. HEMS services and blood banks report favorable experiences implementing and utilizing LTOWB in Norway. The logistics of LTOWB emergency transfusions are manageable and safe in a Norwegian HEMS service.Doktorgradsavhandlin

Effect of pre-hospital blood products on Acute Traumatic Coagulopathy in a model of severe military trauma

Acute traumatic coagulopathy (ATC) is seen in 30% to 40% of severely injured civilian and military casualties. Early use of blood products attenuates ATC, but the timing for optimal effect is unknown. Emergent clinical practice has started pre-hospital deployment of blood components (combined packed red blood cells [PRBC] and fresh frozen plasma [FFP]),but this is associated with significant logistical burden and some clinical risk. It is therefore imperative to establish whether pre-hospital use of blood products is likely to confer benefit. This study compared the potential impact of pre-hospital resuscitation with blood components versus 0.9% saline in a model of severe injury. Terminally anaesthetised Large White pigs received controlled soft tissue blunt injury, controlled haemorrhage (35% blood volume) with or without a primary blast injury followed by a 30-min shock phase. The animals were allocated randomly to one of the two injury arms (blast or sham blast). Within each injury arm the animals were allocated randomly to one of two treatment groups as follows: the shock phase was followed by a 60-min prehospital evacuation phase; comprising hypotensive resuscitation (target systolic arterial pressure 80 mmHg) using either 0.9% saline or blood components (PRBCs:FFP in a 1:1 ratio). Following this phase, an inhospital phase involving resuscitation to a normotensive target (110 mmHg systolic arterial blood pressure) using PRBCs:FFP was performed in all four groups. A coagulopathy developed in both pre-hospital saline groups (increase in TEG [thromboelastography] R and K times and aPTT [activated partial thromboplastin time]) that persisted for 60 to 90 minutes into the inhospital phase. The coagulopathy was attenuated in the pre-hospital blood component groups. Pre-hospital blood component resuscitation may therefore attenuate ATC

Adjuncts to pre-hospital resuscitation strategies for haemorrhagic shock and blast injury : supplemental oxygen and recombinant activated factor VII

M.D. ThesisExplosion is responsible for almost 80% of Coalition injuries in today’s conflicts. Haemorrhage is the leading cause of death and blast lung injury is evident in 11% of Coalition casualties surviving to reach the (UK) Field Hospital. Military prehospital evacuation times can be prolonged and the combined insults of haemorrhage and blast injury present a ‘double hit’ to oxygen delivery. Resuscitation strategies must be capable of preserving life from such trauma for several hours. Alongside fluid therapy, adjuncts to resuscitation might improve battlefield survival. This randomized controlled animal trial assessed two adjuncts: supplemental inspired oxygen and recombinant activated Factor VII (rFVIIa). Neither adjunct is currently available in the far-forward military echelon, but with modern technology, both are potentially deployable. 18 terminally anaesthetized swine were exposed to blast, controlled haemorrhage and grade IV liver laceration (uncontrolled haemorrhage). Animals were allocated randomly into three treatment groups. All animals were resuscitated with normal saline to a hypotensive systolic target (80mmHg), which continued until the 8hr end point. Thirty minutes after the onset of resuscitation each group received one of the following: single (180mcg/kg) dose of rFVIIa; supplemental oxygen (min FiO2 0.3 to maintain SaO2>95%) or the control group (breathed air throughout and received saline placebo 0.18ml/kg). 5/6 control animals died within 4 hours. Supplemental oxygen improved survival (4/6 survival to 8h endpoint, P=0.014). Single dose rFVIIa did not prolong survival compared to control (2/6 survived, p=0.65). Oxygen arrested physiological decline while control and rFVIIa animals continued to decline until death. Supplemental oxygen is a useful adjunct to fluid resuscitation in the context of haemorrhage and blast injury. Delivery of oxygen support capability to forward echelon units is recommended. By contrast, a single intravenous (pre-hospital) dose of rFVIIa was not an effective treatment for blast lung based on our model of complex battlefield injury

Feasibility of combat hemostasis methods in civilian prehospital emergency medical care

Thesis (M.A.)--Boston UniversityUncontrolled hemorrhage is the leading cause of preventable traumatic death in both military and civilian populations. Hemorrhage often causes coagulopathy, which intensifies hemorrhage and complicates its treatment. The armed conflicts in Afghanistan and Iraq have allowed the military to test new hemostatic products and procedures in an effort to better control hemorrhage and reduce its associated morbidity and mortality rates. These methods were analyzed for efficacy and suitability in the civilian prehospital setting. Several invasive and non-invasive interventions were found to be beneficial. Despite centuries of controversy surrounding their use, emergency tourniquets can be safe, lifesaving tools for controlling severe extremity hemorrhage when adequate tourniquet designs are properly used. Hemostatic dressings are very useful as hemorrhage control adjuncts, and two products (Combat Gauze and Celox) are recommended for prehospital use based on their efficacy, mechanisms of action, ease of use, low cost, shelf-life, and other properties. Several pharmacological interventions were evaluated for prehospital use in addressing the anticoagulant and hyperfibrinolytic nature of trauma-associated coagulopathy. Recombinant activated Factor VII, commonly used in hemophiliac-related bleeding, does not improve outcomes in trauma patients. Tranexamic acid, which is commonly used to reduce bleeding in elective surgeries, has been demonstrated to significantly lower mortality in trauma patients with severe hemorrhage, especially when administered within three hours of injury. Recommendations were also made based on the results of military-developed damage control resuscitation protocols: restoration of perfusion is the best way to correct coagulopathy and prehospital fluid administration should be limited to restore perfusion and maintain systolic blood pressures of 80 to 90 mmHg. Hypothermia and hyperthermia are correlated with higher mortality in trauma patients, so temperature management was identified as a top priority in prehospital trauma care. Finally, the properties of stored blood were investigated in the setting of massive transfusion so that paramedics conducting interfacility transfers of these patients could be made aware of common complications to anticipate adverse events

Outcomes following trauma laparotomy for hypotensive trauma patients: A UK military and civilian perspective.

BACKGROUND: The management of trauma patients has changed radically in the last decade, and studies have shown overall improvements in survival. However, reduction in mortality for the many may obscure a lack of progress in some high-risk patients. We sought to examine the outcomes for hypotensive patients requiring laparotomy in UK military and civilian cohorts. METHODS: We undertook a review of two prospectively maintained trauma databases: the UK Joint Theatre Trauma Registry for the military cohort (February 4, 2003, to September 21, 2014) and the trauma registry of the Royal London Hospital major trauma center (January 1, 2012, to January 1, 2017) for civilian patients. Adults undergoing trauma laparotomy within 90 minutes of arrival at the emergency department (ED) were included. RESULTS: Hypotension was present on arrival at the ED in 155 (20.4%) of 761 military patients. Mortality was higher in hypotensive casualties (25.8% vs. 9.7% in normotensive casualties; p < 0.001). Hypotension was present on arrival at the ED in 63 (35.7%) of 176 civilian patients. Mortality was higher in hypotensive patients (47.6% vs. 12.4% in normotensive patients; p < 0.001). In both cohorts of hypotensive patients, neither the average injury severity, the prehospital time, the ED arrival systolic blood pressure, nor mortality rate changed significantly during the study period. CONCLUSIONS: Despite improvements in survival after trauma for patients overall, the mortality for patients undergoing laparotomy who arrive at the ED with hypotension has not changed and appears stubbornly resistant to all efforts. Specific enquiry and research should continue to be directed at this high-risk group of patients. LEVEL OF EVIDENCE: Prognostic/Epidemiologic, level IV

Physical and cognitive performance after blood donation : A clinical study to investigate donor safety in walking blood banks

De siste 20 årene har fullblod til pasienter i blødningssjokk blitt re-lansert som foretrukket behandling. I vandrende blodbanker blir blodet oppbevart i original forpakningen inntil behovet oppstår. Konseptet har logistiske fordeler, er kost effektivt og bevarer tilgang til fullblod både når man er på oppdrag langt fra andre ressurser eller ved kriser. Vandrende blodbanker utgjør i dag grunlaget for nasjonale planer for blodberedskap i Norge. Marinejegerkommandoen etablerte vandrende blodbanker blant deres soldater for å sikre tilgang til fullblod på oppdrag med lange evakuerings akser. I den forbindelse ble det reist spørsmål om mulig reduksjon i yteevnene og soldatferdigheter like etter blodgivning. Litteratursøk gav ikke tilfredsstillende svar på spørsmålene. Derfor ble det designet en studie for å utforske hvordan blodgivning påvirket spesialsoldatenes utholdenhet og ferdigheter, samt om det var mulig å lære ikke-sanitetspersonell tappe prosedyrer. I Artikkel I fant vi hverken redusert maksimalt oksygenopptak eller reduserte ferdigheter hos uthvilte soldater. Det var og 100% suksessrate for opplæring i tappeprosedyrer. Dette førte til at Marinejegerkommandoen etablerte vandrende blodbanker blant sine soldater. Funnene var gjort hos uthvilte soldater og kunne trolig ikke overføres til slitne soldater på slagmarken. Neste studie undersøkte derfor effekten av standard blodgivning hos utslitte soldater. Artikkel II viste ett fall i maksimalt oksygen opptak på 6%, noe som var akseptabelt for Marinejegerkommandoen. I Norge kan avstander mellom sykehus være lange og været ofte utfordrende. Derfor er vandrende blodbanker brukt også sivilt. Dette gjorde det naturlig å designe en studie som undersøkte effekten av blodgivning på fysisk og kognitiv yteevne hos vanlige blodgivere, og i Artikkel III fant vi 7% reduksjon i maksimalt oksygenopptak og bevart kognitiv yteevne. Vandrende blodbanker er et trygt og effektivt system for å sikre tilgang til fullblod ved kriser eller ved lange evakuerings og forsynings akser. Å gi blod påvirker blodgiverens yteevne i begrenset grad, men å gi blod i en krisesituasjon kan sette blodgiveren i fare om han eller hun skulle bli den neste pasienten. Fremtidige studier er ønsket for å sikre funnen samt å undersøke effekten av blodgivning under andre miljømessige forhold.Whole blood transfusion for patients in hemorrhagic shock has been re-introduced over the last two decades. In walking blood banks, the blood is stored in the original container until needed. The concept is logistically feasible, cost-effective, and provides access to whole blood where blood bank services are unavailable. Walking blood banks are important in Norwegian health care`s blood preparedness plans. The Norwegian Naval Special Operations Command identified walking blood banks as the only option to ensure whole blood availability in far-forward missions. However, a major concern was that blood donation would compromise the soldiers’ skills, and the literature did not provide convincing evidence to implement the system. Therefore, a study was designed to investigate feasibility; would blood donation affect elite soldiers' endurance and shooting capabilities – and would it be possible to train non-medics in blood donation procedures? As shown in Paper I, we did not find reduced maximal oxygen consumption or impaired soldier skills in rested soldiers. There was a 100% success rate in teaching non-medics in whole blood donation and transfusion procedures. The Naval Special Operations Command approved walking blood banks based on these findings. However, as the study was conducted on rested soldiers, the results could not be transposed to soldiers in combat situations. The next study accordingly was designed to investigate the physical performance of fatigued soldiers immediately after blood donation. Paper II showed a 6% reduction in maximal oxygen consumption in fatigued soldiers, which was considered acceptable by the Command. In Norway, with long transportation distances and challenging weather conditions, a walking blood bank is considered a real possibility, also in civilian settings. It was consequently logical to include regular blood donors in the third paper: Would their physical and cognitive functions significantly reduce after blood donation? In Paper III, we report a 7% reduction in maximal oxygen consumption and that cognitive performances were maintained in regular blood donors. A standard blood donation causes a decrease in exercise physiology, does not affect cognitive physiology, and maintains performance. Therefore, walking blood banks are feasible and provide resilience. However, some of the risks involved should be acknowledged. Future quality data is warranted to reduce residual risk, especially in different environmental settings.Doktorgradsavhandlin

The forgotten cohort-lessons learned from prehospital trauma death: a retrospective cohort study.

BACKGROUND Trauma related deaths remain a relevant public health problem, in particular in the younger male population. A significant number of these deaths occur prehospitally without transfer to a hospital. These patients, sometimes termed "the forgotten cohort", are usually not included in clinical registries, resulting in a lack of information about prehospitally trauma deaths. The aim of the present study was to compare patients who died prehospital with those who sustained life-threatening injuries in order to analyze and potentially improve prehospital strategies. METHODS This cohort study included all primary operations carried out by Switzerland's largest helicopter emergency medical service (HEMS) between January 1, 2011, and December 31, 2021. We included all adult trauma patients with life-threatening or fatal conditions. The outcome of this study is the vital status of the patient at the end of mission, i.e. fatal or life-threatening. Injury, rescue characteristics, and interventions of the forgotten trauma cohort, defined as patients with a fatal injury (NACA score of VII), were compared with life-threatening injuries (NACA score V and VI). RESULTS Of 110,331 HEMS missions, 5534 primary operations were finally analyzed, including 5191 (93.8%) life-threatening and 343 (6.2%) fatal injuries. More than two-thirds of patients (n = 3772, 68.2%) had a traumatic brain injury without a significant difference between the two groups (p > 0.05). Thoracic trauma (44.6% vs. 28.7%, p < 0.001) and abdominal trauma (22.2% vs. 16.1%, p = 0.004) were more frequent in fatal missions whereas pelvic trauma was similar between the two groups (13.4% vs. 12.9%, p = 0.788). Pneumothorax decompression rate (17.2% vs. 3.7%, p < 0.001) was higher in the forgotten cohort group and measures for bleeding control (15.2% vs. 42.7%, p < 0.001) and pelvic belt application (2.9% vs. 13.1% p < 0.001) were more common in the life-threating injury group. CONCLUSION Chest decompression rates and measures for early hemorrhage control are areas for potential improvement in prehospital care