Practical Guidance for Prehospital Transfusion by Emergency Medical Services

The rapid expansion to 46 U.S. states underscores the growing acceptance of prehospital transfusion by Emergency Medical Services (EMS) as a lifesaving intervention, though implementation is heterogeneous across jurisdictions and dependent on medical oversight, logistics, and reimbursement. PLUS is highlighting two articles this month, beginning with a review by Levy et al ¹ of the history of EMS in the United States. The initial role of EMS was patient transport with some lifesaving interventions such as cardiopulmonary resuscitation added later. The skills and expertise of modern EMS staff have benefited from surgical and medical knowledge regarding trauma resuscitation gained from the battlefield, resulting in a much higher level of patient care prior to hospital arrival. Administering blood products and medications, stabilizing fractures, and controlling bleeding are part of the modern EMS skill set. The article contains a useful table clarifying EMS clinicians’ scope of practice. EMS blood transfusion is currently performed or in progress in 46 U.S. states.² Most EMS systems (70%) transfuse low titer O+ whole blood (LTOWB); 14% administer combinations of liquid plasma (LP), LTOWB, and red blood cells; and 1% use only LP.

Successful patient outcomes require clear and standardized communication between hospitals and EMS systems, adherence to federal and state regulations, local medical support, and a well-structured program. The Prehospital Blood Transfusion Coalition’s Clinical Practice Guideline (CPG) for civilian EMS is detailed in the second article, by Levy et al.³  The CPG is a guide to implementing prehospital blood transfusion.

Among the stakeholders are the community that will be affected by a prehospital transfusion program; the receiving hospital, including its blood bank; the blood supplier; and EMS teams. Local or state policy makers may be helpful in supporting the program. As noted in the first article, there may be concerns regarding reimbursement.

Education and training of all stakeholders must occur before the program starts at regular intervals thereafter. Full medical oversight must be instituted, with every prehospital transfusion case undergoing review. A robust quality program must be in place.

The CPG defines prehospital principles of resuscitation and transfusion, which include rapid recognition of hemorrhagic shock signs and symptoms. The guidelines specify hemorrhage control methods, vascular access and blood product options, measures to prevent hypothermia, tranexamic acid (TXA) use guidelines, and calcium replacement guidance for pediatric and adult patients. Caution to limit crystalloids to less than half a liter is given, to reduce hemodilution and coagulopathy.

Clinical criteria for transfusion are listed. EMS team members are reminded to evaluate conscious patients for refusal to be transfused and to quickly assess other patients for medical bracelets or documents that may indicate their objection to receipt of allogeneic blood products.

The role of EMS is not to administer Rh immune globulin in trauma resuscitation when Rh positive products are given to Rh negative recipients but should relegate this activity to the receiving facility.  The authors list equipment needed by EMS for the proper administration of blood products as well as blood storage requirements and describe how to visually inspect the components. Blood product identification prior to transfusion includes verification of blood product type, blood type, donation identification number, and expiration date. The patient must be monitored prior to, during, and after transfusion for any signs and symptoms of a transfusion reaction. Patients with anaphylactic reactions may receive specific treatment during transport. Any suspected reaction should be reported to the receiving hospital. Transferring the patient with their blood product bags to hospital teams is the last step of the EMS handoff.

Complete documentation for all care provided by the EMS team, especially blood product administration, may seem onerous but is critical for maintaining the EMS system’s compliance with requirements of regulatory agencies (e.g., FDA) and accrediting organizations (e.g., AABB).

The American Red Cross provides blood products for prehospital transfusion. Follow the link for more information. https://www.redcrossblood.org/biomedical-services/blood-products-and-services.html.⁴

References

1. Levy MJ, Young PP, Bank E, Coberly E, Holcomb JB, Guyette FX, Schaefer RM, Krohmer JR. Contemporary prehospital Emergency Medical Services in the United States: an overview and considerations for the transfusion medicine community. Transfusion. 2025; 65(9):1738-1745.  https://doi.org/10.1111/trf.18348
2. Prehospital Blood Transfusion Coalition. EMS Transfusion Scope of Practice. https://prehospitaltransfusion.org/ems-transfusion-scope-of-practice/. Cited 2025 Nov 12.
3. Levy MJ, Schaefer RM, Obyrne H, Krohmer JR, Bank EA, Holcomb JB. Prehospital blood transfusion coalition clinical practice guidelines for civilian emergency medical services. Trauma Surg Acute Care Open. 2025;10; 2025 Jul 16;10(3):e001931. https://doi.org/10.1136/tsaco-2025-001931
4. The American National Red Cross. Blood Products and Services. https://www.redcrossblood.org/biomedical-services/blood-products-and-services.html. Cited 2025 Nov 12.