Implementation and Execution of Civilian Remote Damage Control Resuscitation Programs

Abstract

Remote damage control resuscitation is a recently defined term used to describe techniques and strategies to provide hemostatic resuscitation to injured patients in the prehospital setting. In the civilian setting, unlike the typical military setting, patients who require treatment for hemorrhage come in all ages with all types of comorbidities and have bleeding that may be non-trauma related. Thus, in the austere setting, addressing the needs of the patient is no less challenging than in the military environment, albeit the caregivers are typically not putting their lives at risk to provide such care. Two organizations have pioneered remote damage control resuscitation in the civilian environment: Mayo Clinic and Royal Caribbean Cruises Ltd. The limitations in rural Minnesota and shipboard are daunting. Patients who have hemorrhage requiring transfusion are often hundreds of miles from hospitals able to provide damage control resuscitation. This article details the development and implementation of novel programs specifically designed to address the varied needs of patients in such circumstances. The Mayo Clinic program essentially takes a standard-of-care treatment algorithm, by which the patient would be treated in the emergency department or trauma bay, and projects that forward into the rural environment with specially trained prehospital personnel and special resources. Royal Caribbean Cruises Ltd has adapted a traditional military field practice of transfusing warm fresh whole blood, adding significant safety measures not yet reported on the battlefield (see within this Supplement the article entitled "Emergency Whole Blood Use in the Field: A Simplified Protocol for Collection and Transfusion"). The details of development, implementation, and preliminary results of these two civilian programs are described herein.

RePHILL: protocol for a randomised controlled trial of pre‐hospital blood product resuscitation for trauma

“…Experts in the field have called for ‘prospective studies… to clarify the role of [freeze‐dried plasmas] and RBCs in civilian prehospital hemorrhagic shock resuscitation’ (Sunde et al, ) and have stressed the importance of ‘high‐quality prospective …data collection’ (Jenkins et al, ). A prospective observational study recently reported no evidence of superiority of PHBP in reducing mortality, but was limited by significant differences in trauma burden and physiology between patients retrieved by PHBP‐capable services compared to those transported without access to PHBP (Holcomb et al, ).…”

Damage-control resuscitation and emergency laparotomy

“…In contrast, these results may not be as applicable in rural America and the developing world, where RBCs, thawed plasma and platelets are in limited supply, limiting access to therapies, such as damage control resuscitation. To improve trauma care in these settings, novel blood products 10, 11 , such as lyophilized plasma 12 , and freeze dried platelets are being developed but are not yet available in the United States.…”

Prehospital plasma resuscitation associated with improved neurologic outcomes after traumatic brain injury

“…Our institution began transfusing pRBC in the prehospital setting in 1988 and thawed plasma in February of 2009 (16). Currently, thawed plasma is transfused first and then the units are alternated between pRBC and thawed plasma in patients with hemodynamic instability.…”