Mark Piehl

Prehospital blood is increasingly common. Is permissive hypotension in trauma a thing of the past? @JakeBroome @SydneyCaputo @markpiehl #WTA2026

@WesternTrauma @JakeBroome @SydneyCaputo We definitely need to re-evaluate traditional permissive hypotension targets when blood is transfused in the field. This study and another presented this week @WesternTrauma suggest 110 may be optimal, even for NCTH. Less duration of shock = better outcomes

Thank you @HandtevyMD for sharing this amazing case and for the incredible care provided by the Palm Beach County Fire Rescue and City of Palm Beach Gardens EMS crews! Similar to the trauma case you presented a few weeks ago, this patient needed active resuscitation provided quickly so that BP and perfusion could be restored and he didn't progress to cardiac arrest. The immediate improvement in mental status tells the story. Obviously I'm biased, but for patients with severe shock like you describe here, gravity or a pressure bag just can't deliver the fluid (or blood in hemorrhagic shock) needed when minutes truly matter. This is particularly true with an IO. You also show that effective resuscitation doesn't mean a lot of fluid, rather just enough given quickly to reverse shock. That's the point of LifeFlow

🚨 𝐀 𝐜𝐚𝐥𝐥 𝐈’𝐥𝐥 𝐧𝐞𝐯𝐞𝐫 𝐟𝐨𝐫𝐠𝐞𝐭. Yesterday, we were toned out to a cardiac arrest—a man stung multiple times by wasps, now unconscious and in severe respiratory distress. 𝐁𝐲 𝐭𝐡𝐞 𝐭𝐢𝐦𝐞 𝐈 𝐚𝐫𝐫𝐢𝐯𝐞𝐝, 𝐡𝐞 𝐰𝐚𝐬 𝐢𝐧 𝐭𝐡𝐞 𝐛𝐚𝐜𝐤 𝐨𝐟 𝐭𝐡𝐞 𝐚𝐦𝐛𝐮𝐥𝐚𝐧𝐜𝐞: ✧ Humeral IO placed ✧ BVM ventilations underway ✧ No radial pulse ✧ No measurable BP In the next few minutes, the team delivered: ✅ IM Epinephrine ✅ Push-dose pressor Epi (6x1 mL = 60 mcg) ✅ Benadryl ✅ Solumedrol ✅ Inline Albuterol ✅ Initial NS bolus (via gravity) Sats improved. A faint radial pulse returned. BP 90/p. Still unconscious. Then came the moment that changed everything: 𝘐 𝘢𝘴𝘬𝘦𝘥 𝘵𝘩𝘦 𝘌𝘔𝘚 𝘊𝘢𝘱𝘵𝘢𝘪𝘯 𝘵𝘰 𝘨𝘳𝘢𝘣 𝘵𝘩𝘦 𝘓𝘪𝘧𝘦𝘍𝘭𝘰𝘸 𝘳𝘢𝘱𝘪𝘥 𝘪𝘯𝘧𝘶𝘴𝘦𝘳. 🔄 Three minutes and 700 mL later... He opened his eyes and smiled at us. 𝐖𝐡𝐚𝐭 𝐈 𝐰𝐢𝐭𝐧𝐞𝐬𝐬𝐞𝐝 𝐟𝐢𝐫𝐬𝐭𝐡𝐚𝐧𝐝 𝐰𝐢𝐥𝐥 𝐧𝐞𝐯𝐞𝐫 𝐥𝐞𝐚𝐯𝐞 𝐦𝐞. We’ve used LifeFlow for whole blood delivery—but today, it saved a life through rapid crystalloid infusion. This man didn’t just need epi—he needed volume. And fast. As the ED doors opened, the staff expecting a full arrest was greeted by a smiling patient. And our team? We couldn’t stop smiling either. 🙏 Huge thanks to @markpiehl and the entire team at @LifeFlow__ . Your innovation made the difference between life and death. 📌 Note 1: I have no COI (I wish I did). 📌 Note 2: The video was created using AI 😃

Is the Surviving Sepsis Campaign fluid recommendation of 30mL/kg safe & effective? Turns out it is. Not every patient with sepsis may need 30mL/kg, but for septic shock (SBP < 90 and/or lactate >4), 30mL/kg by 3hrs is associated with lower mortality and less mechanical ventilation. And 20-30mL/kg in the 1st hour may be the optimal volume and timing for these patients. Check out our observational study of 1600 patients @WakeMed here: journals.lww.com/ccejournal/ful… #sepsis @SCCM #CritiCareExplore

@VCFD_PIO @OxnardFire @CountyVentura @AMRVENTURA @VCMC_TraumaDept @VitalantCA Thank you @VCFD for sharing this incredible story and for saving a life by delivering whole blood within minutes of arrival to the scene. You are leading the way to improved trauma care in California, hopefully many other agencies will soon follow!

VCFD Firefighter Paramedics delivered the first pre-hospital blood transfusion in California yesterday. Firefighters arrived on scene of a critically injured stabbing victim with Oxnard PD, Oxnard Fire and Gold Coast Ambulance. The patient was unconscious with unstable vital signs. While transporting the patient to Ventura County Medical Center, VCFD paramedics quickly prepared and administered a unit of whole blood. The response was swift and effective. The patient’s vital signs improved en route: skin signs normalized, and the patient regained consciousness and was able to speak to the crew. The historic incident underscores the success of a highly coordinated, multi-agency effort involving the Ventura County Fire Department, the Ventura County Emergency Medical Services (EMS) Agency, and Ventura County Medical Center (VCMC) — all working together to bring this advanced lifesaving capability to the field. The groundbreaking use of field transfusion in this case has already demonstrated its lifesaving potential — and Ventura County is proud to lead the way in setting a new standard for trauma care across California. Photo: VCFD, Oxnard Fire and Gold Coast Ambulance transferring patient care to the trauma team at VCMC. #VCFD #venturacountyfire #firefighter #paramedic #ems #bloodtransfusion #prehospital #oxnardfire #oxnardPD #goldcoastambulance #vcmc #trauma

Thank you @DrJeffJarvis for a thoughtful review of our Faster Refill paper! You do make some fair points about potential methods improvements while acknowledging the strength of the results, which are the first ever to show a trauma survival benefit for blood in urban EMS @HandtevyMD @JakeBroome

The @dcfireems team under the leadership of Holly O’Byrne and @EMSPhysician David Vitberg has saved many lives, again disproving the myth that urban agencies with short transport times shouldn’t carry blood. This will be an incredible webinar!

Exactly @HandtevyMD! This paper nicely addresses Myth #1 in the prehospital trauma debate: we are too close to the trauma center to bother carrying blood. Well, the data here show that for penetrating trauma with hemorrhagic shock, every single minute of delay in starting blood (and delivering an adequate volume to reverse shock) increases mortality by 11%. We don’t magically start effective resuscitation the minute a patient hits the trauma bay doors, therefore our EMS colleagues can do a whole lot of good getting that resuscitation started closer to the point of injury!

@JTraumAcuteSurg @Tulane_Surgery @JakeBroome Yes it does! For penetrating trauma with hemorrhagic shock, very single minute of delay in starting blood (and delivering an adequate volume to reverse shock) increases mortality by 11%. This is one of the best arguments for deploying prehospital blood in ground EMS

Our data suggest that prioritization of prehospital transfusion improves survivability in patients with severe hemorrhage despite a modest increase in transport time. @Tulane_Surgery @MarkPiehl @JakeBroome journals.lww.com/jtrauma/abstra…

Thanks @FireMedic40NJ it was a total privilege to join Mike Carunchio and @HandtevyMD on Okayest Medic! We discussed the recent @AcademicEmerMed article suggesting there isn’t enough evidence for blood in ground EMS, and our editorial challenging the authors. onlinelibrary.wiley.com/doi/10.1111/ac… onlinelibrary.wiley.com/doi/full/10.11… If you can’t access our letter, here’s the basic summary: Schoenfeld & colleagues analyzed three RCT’s on prehospital blood including: PAMPer - an air medical trial of plasma for trauma COMBAT - an urban EMS study of thawed plasma, and RePHILL - a UK air medical trial comparing blood products to crystalloid Only PAMPer showed some benefit during 40 minute transports, and in RePHILL resuscitation wasn’t actually started until about 50 min after EMS arrival. None evaluated the “advanced resuscitative care” package of blood, TXA, and calcium currently administered fast-paced ground EMS agencies, which is the new damage control resuscitation: immediate hemorrhage control where possible, basic airway support, and rapid hemostatic resuscitation with blood to reverse hemorrhagic shock en route, then advanced airway only when necessary after transfusion. Outcomes from @NewOrleansEMS, @dcfireems , Grady EMS, @TidewaterEMS, Orange County (Fl), Palm Beach County Fire Rescue, BSO, and so many others tell the story. Importantly, the Faster Refill study from New Orleans showed an odds ratio of 0.2 for mortality among patients who got blood, a huge survival benefit. We conclude our letter by countering the Schoenfeld, et al claim that there is still equipoise on prehospital transfusion vs the old standard of care. Many details still need some good research, but we know now that early transfusion in the field saves lives @SPARC2024

Does every meaningful clinical innovation really require an RCT before it's widely deployed, as Schoenfeld & colleagues suggest in their meta-analysis on prehospital transfusion for trauma? Our editorial questions the relevance of the studies they review and points to evidence, and to the recent experience of many urban and rural EMS agencies, supporting early resuscitation with blood closer to the point of injury. onlinelibrary.wiley.com/doi/10.1111/ac… onlinelibrary.wiley.com/doi/full/10.11… @HandtevyMD @ResusOne

@georgoff @LifeFlow__ Yes sir @georgoff the team at @dcfireems is doing an incredible job bringing effective resuscitation with whole blood close to the point of injury. Excluding field arrests, survival for their critically ill trauma patients is 90%

I spy ⁦@LifeFlow__⁩ in action! D.C. medics save trauma victims with on-site blood transfusions - The Washington Post washingtonpost.com/dc-md-va/2024/…

@Eddyjoemd you are right less fluid in ICU is better, but this article misses the point: early fluid titrated to shock reversal, not liberal or restrictive, improves patient outcomes. 2 abstracts at #ACEP24 this week showed lower mortality, less mechanical ventilation, and lower cost among septic shock patients who got 30mL/kg before the 3rd hour, consistent with the earlier work of @hanikuttab & Michael Ward. Similarly a recent #SAEM24 abstract showed the lowest mortality for septic shock patients who received 20-30mL/kg in the 1st hour. Like CLOVERS, the Taniguchi paper has nothing to do with effective early resuscitation in EMS & ED ncbi.nlm.nih.gov/pmc/articles/P… nejm.org/doi/full/10.10…

Arbitrary, overly-aggressive IV fluid resuscitation without a hemodynamic target outside of MAP has never sat well with me. This short and to the point paper explores data as to why we shouldn’t open the flood gates. 🎩 tip to the authors. eddyjoemd.com/foamed/

@DanielRGerard @EaglesGather @1stThere1stCare @Tulane_Surgery @dcfireems @dcfireemsfound @SATXFire @PBFireRescue @ProdigyEMS @maiadorsett @UKROBL1 @gateshil @HandtevyMD Hi Dan, we're saying blood should be given as close to point of injury as possible AND that rapid transport is important. Both are possible. Most important is time to adequate resuscitation with blood. Every minute of delay in starting transfusion increases mortality by 11%

@EaglesGather @1stThere1stCare @Tulane_Surgery @dcfireems @dcfireemsfound @markpiehl @SATXFire @PBFireRescue @ProdigyEMS @maiadorsett @UKROBL1 @gateshil @HandtevyMD I agree that blood resuscitation is imperative to survival, but are you saying that rapid transport to definitive care is no longer necessary?

“It’s a new era. Stop the ridiculous dogma of #EMS rushing exsanguinating patients to the hospital. Empower EMS clinicians to #resuscitate with blood.” Juan Duchesne #EaglesGather24 @1stThere1stCare @Tulane_Surgery #SPARC2024

@armyemdoc @JTraumAcuteSurg @LifeFlow__ Thanks Steve! Still not clear exactly how each element contributed to improved mortality, but a simple bundle for hemorrhagic shock seems to work well, even with short transport (~8 min). The most important component is of course the blood, but TXA and calcium probably help too

Should prehospital trauma care be driven by "bundles" rather than a salad bar approach? This study suggests yes. In this "advanced resuscitative care" bundle, patients with penetrating trauma and hypotension receive a bundle of blood via LifeFlow, calcium, and TXA. Those who received the bundle had mortality odds of 0.19 (0.05-0.68). IMO, this simplified approach will do more good for patients when you have a well-greased, simplified system. However, I'm not sure about the empiric calcium. journals.lww.com/jtrauma/abstra… #emergency #emergencymedicine #foam #foamed #foamcc #army #armymedicine #armyemdoc #meded #icu #criticalcare #trauma #blood #military #shock #combat #navy #airforce #marines #medx #medtwitter

@HandtevyMD Incredible #AAST2023 presentation today from @KristenNordham & @JakeBroome first blood study to show mortality benefit for severe trauma in ground EMS, reducing “dead zones” where no resuscitation is provided. Juan & @NewOrleansEMS @DrMegMarino @Tulane changing the world!

If you’re in EMS and are looking to start your blood program, know that a Trauma Surgeon from New Orleans is your biggest advocate. Dr. Duchesne’s newest data proves, without a doubt, that prehospital blood, given early, significantly improves mortality. #WorldTraumaSymposium @EMSWorldOFCL

@HandtevyMD So inspiring to hear Juan and the whole @NewOrleansEMS team share their experience, the first group to show mortality improvement with blood for NCTH in ground EMS, paper this Friday @AAST @DrMegMarino @NewOrleansEMS #WorldTraumaSymposium @EMSWorldOFCL

@HandtevyMD @EM_RESUS @armyemdoc @LifeFlowInfuser @QinfloWarrior Peter this case was not through IO, but Sam yes you can give 500ml in < 2min, which is how he was resuscitated effectively in minutes before intubation. See data here from NOEMS: 2u PRBCS’s + TXA + Ca in 9 min transport for NCTH, low mortality, 50% had humeral head IO

@EM_RESUS @armyemdoc @LifeFlowInfuser @QinfloWarrior Sam - Here’s an actual video of a trauma patient getting 500 mL LTOWB in 2 minutes with the @LifeFlowInfuser. youtu.be/unog3YkFSOE (scroll to 25:15). @markpiehl can you confirm this was via the IO?

A hypotensive trauma patient arrives in your ED without access, do you... (a) Go straight to IO (b) Attempt IV (c) Fumble around with a central line because you think you are faster than what you actually are A prospective study of 581 patients with 1410 attempts in @JTraumAcuteSurg found that IO was far superior in first-attempt access over IV and CVC (93% vs 67% vs 59%). journals.lww.com/jtrauma/Abstra… #emergency #emergencymedicine #icu #criticalcare #trauma #injury #foamed #foamcc #data #science #research #armyemdoc #medtwitter