Terrorist Attacks: Transfusion Specialists’ Point of View.
Authors: Dann Eldad J. , Bonstein Lilach , Kornberg Abraham , Rahimi-Levene Naomi 
Published: April 2020

Abstract
The issue of mass casualties in civilian population has lately become globally relevant and prevalent. Explosions of loaded busses by suicide bombers as well as explosions in crowded public places create a great number of casualties, many of them being children and several members of same families, who are evacuated by scoop and run method to nearby hospitals. We report on potential hazards of massive blood transfusions to multi-trauma patients, simultaneously admitted to hospital. Upon admission to the emergency room (ER) ID and personal details of patients are recorded and a temporary ID badge is issued for unidentified patients. Then, a blood sample for typing and screening is taken and required blood is ordered. Primary blood supply for patients with unstable condition, who need immediate blood transfusion, is O Rh positive packed cells (for fertile females O Rh negative) until the ABO and Rh blood groups are established. In order to avoid misidentification our routine includes presence of a blood bank representative in the ER for confirming identification of patients and correct labeling of blood samples. 2 individuals must identify patients from whom samples are taken. In the operating rooms (OR) another blood bank representative (either a transfusion medicine specialist or a hematologist) matches blood types and identification numbers, maintains contact with the blood bank, conveys information to anesthesiology team and advises them on replacement therapy. 7 terrorist attacks resulted in a total of 55 patients, evacuated to 2 hospitals in Israel. 285 packed cells units were typed and cross-matched for these patients. The amount of packed cells supplied during the first 2 hours was 47% of the total blood supplied during the first 24 hours. The cross-matched/transfused ratio varied from 1.3 to 2.19 reflecting overestimation of blood requirement during mass casualty episodes. One “near-miss” was prevented in OR when two members of the same family were operated on in adjacent rooms. Units for one of these patients were misplaced. ABO incompatibility is one of the major causes of morbidity and mortality resulting from blood transfusions. Signs and symptoms are masked in an anesthesized patient. The fact that units of blood accumulate at patient’s bedside upon being deleted from the blood bank inventory may be misinterpreted as a shortage of blood supply in the blood bank. There is also a potential for errors in matching units of blood to patients both in ER and OR. In the setup of mass casualties influx the blood bank personnel should be on alert for the following potential Achilles’ heels: misidentification of the patient when taking a blood sample for typing and screening or misidentification of the patient who needs to receive the blood product. Reasons for these may be either one digit difference in serial temporary number of unidentified patients, being operated on simultaneously in nearby rooms, or several family members undergoing simultaneous surgery in adjacent OR. Such errors can be minimized by using a 3-digit bold number in addition to the running temporary ID and thus providing 2 identification parameters. Our data suggest that the amount of blood products ordered for such patients is excessive. Surgical teams should be aware of the possibility to have blood components kept on hold in the blood bank instead of accumulating them in ER and OR and risking misidentification and suboptimal storage conditions.