1. In-flight Damage Control Resuscitation of massive bleeding – challenges and opportunities during long flights. A Case Report   Peter Martin Hansen, MD, Jakob Stensballe, MD, PhD

2. Danish Air Ambulance/HEMS Denmark
In-flight Damage Control Resuscitation of massive bleeding – challenges and opportunities during long flights. A Case Report   Peter Martin Hansen, MD, Jakob Stensballe, MD, PhD
Danish Air Ambulance/HEMS Denmark
Three bases in Skive, Billund and Ringsted
3-crew concept: DOC, pilot, HEMS Crew member
Airbus EC-135 P2+
VFR/IFR/NVG/PINS
24/7/365
In average 3 mission/base/day
2 RBC and 2 plasma on board

3. Severe blunt truncal injuries, male 24 yrs old
In-flight Damage Control Resuscitation of massive bleeding – challenges and opportunities during long flights. A Case Report x 24  Peter Martin Hansen, MD, Jakob Stensballe, MD, PhD
Severe blunt truncal injuries, male 24 yrs old
Remote location, 104 NM distance, fuel considerations/options
Damage Control Rescuscitation initiated before HEMS arrival
FAST & X-rays: massive bleeding, multiple injuries, pelvic fracture, head trauma
2 chest tubes, pelvic sling, multiple IV lines, CVC, a-line
Medical ambition: Transfer to Level 1 Trauma Centre

4. In-flight, 50 mins flying time: 7 RBC 4 plasma 1 l Albumin
In-flight Damage Control Resuscitation of massive bleeding – challenges and opportunities during long flights. A Case Report   Peter Martin Hansen, MD, Jakob Stensballe, MD, PhD
Before HEMS take-off:
5 RBC
2 l Albumin
3,5 l crystalloid
TXA 2 g
In-flight, 50 mins flying time:
7 RBC
4 plasma
1 l Albumin
2,5 l crystalloid
2 pressure perfusors Golden Hour Container
SBT 60-80
Spontaneous breathing on ET tube, ETCO , RF 8-10/min
S-Ketamine, Fentayl, Noradrenalin microg/kg/min

5. 2 platelet concentrates (4 donors) TXA 2 g
In-flight Damage Control Resuscitation of massive bleeding – challenges and opportunities during long flights. A Case Report   Peter Martin Hansen, MD, Jakob Stensballe, MD, PhD
In Trauma Centre:
13 RBC
13 plasma
2 platelet concentrates (4 donors)
TXA 2 g
Damage Control laparotomy/thoracotomy
Injuries were deemed unsurvivable and further treatment futile

6. On arrival in Trauma Centre: Coagulopathy: INR 1,7
In-flight Damage Control Resuscitation of massive bleeding – challenges and opportunities during long flights. A Case Report   Peter Martin Hansen, MD, Jakob Stensballe, MD, PhD
On arrival in Trauma Centre:
Coagulopathy: INR 1,7
TEG: decreased platelet/fibrinogen function

7. Massive in-flight rescuscitation of blood products is feasible
In-flight Damage Control Resuscitation of massive bleeding – challenges and opportunities during long flights. A Case Report   Peter Martin Hansen, MD, Jakob Stensballe, MD, PhD
Conclusions:
Massive in-flight rescuscitation of blood products is feasible
Damage Control Rescuscitation aiming at 1:1:1 of RBC, plasma and platelets should be prioritized to avoid dilution and further coagulopathy
On-board blood products optimally shoud consist of all three since local hospital transfusion support is scarce

8. 2. Effect of plasma in prehospital phase – Randomized Controlled Trial
In-flight Damage Control Resuscitation of massive bleeding – challenges and opportunities during long flights. A Case Report   Peter Martin Hansen, MD, Jakob Stensballe, MD, PhD
Discussion:
Feasiblility of prehospital Damage Control Rescuscitation is demonstrated
How can we improve:
1. Platelet function: evaluation in the prehospital phase and on arrival in hospital.
2. Effect of plasma in prehospital phase – Randomized Controlled Trial
3. Effect of prehospital platelet transfusion – Randomized Controlled Trial

9. Recent/current studies on the way:
In-flight Damage Control Resuscitation of massive bleeding – challenges and opportunities during long flights. A Case Report   Peter Martin Hansen, MD, Jakob Stensballe, MD, PhD
Discussion:
Recent/current studies on the way:
PATCH TRIAL – TXA study from Australia. Recap of CRASH2 but starting in the prehospital phase
Prehospital Administration of Tranexamic Acid i Trauma Patients
Crit Care :143. Wafaisade et al.
Significantly improved early survival , prolonged time to death, the more injured, the better the effect of TXA, recommends first dose of TXA en route to hospital

10. Recent/current studies on the way:
In-flight Damage Control Resuscitation of massive bleeding – challenges and opportunities during long flights. A Case Report   Peter Martin Hansen, MD, Jakob Stensballe, MD, PhD
Discussion:
Recent/current studies on the way:
RePHILL – Resuscitation with Prehospital Blood Products
Randomization between crystalloid 1 l 0.9% saline or 2 RBCs + 2 Plasma to traumatic injury resulting in hemorrhage
HEMS setting in Austria very similar to Danish Air Ambulance/HEMS Denmark
Fibrinogen concentrate in trauma patients, presumed to bleed
Fries et al
Severely traumatized patients with visible significant and/orclinical signs of severe bleeding are randomized to either placebo or Fibrinogen according to weight.
HEMS/Physician Manned Ambulance setting in Austria and Germany

11. In-flight Damage Control Resuscitation of massive bleeding – challenges and opportunities during long flights. A Case Report   Peter Martin Hansen, MD, Jakob Stensballe, MD, PhD
THANK YOU – FLY SAFE