Blood transfusion preparedness for mass casualty incidents: Are we truly ready?


  • James R. Stubbs, MD
  • Donald H. Jenkins, MD



mass casualty incidents, transfusion support, blood supply


Mass casualty incidents (MCI) are high profile contributors to the number of annual trauma-related deaths in the United States. A critical aspect of MCI care is the ability to provide blood components in sufficient types and quantities to prevent deaths due to hemorrhage. For transfusions to play an optimal role in the prevention of trauma-related hemorrhagic death, including MCI, there appears to be a very tight time window after injury to initiate transfusion therapy. In order to meet this tight window, blood components of appropriate numbers and quantities must be immediately available. Currently, it is questionable whether standing blood inventories at US healthcare facilities are sufficient to appropriately meet the transfusion needs of a surge of MCI victims. Previous models of blood supply adequacy have focused on the availability of red blood cells, and the ability to move blood components quickly from blood suppliers to impacted healthcare facilities. These models have not considered the adequacy of other critically necessary blood components, such as platelets. A recent simulation of blood product demand after MCI showed that, in order to meet the defined RBC needs of 100 percent of casualties, a hospital would need 13-14 units in inventory per casualty. This simulation did not evaluate requirements for platelets and plasma, which would likely be extensive. Meeting balanced resuscitation demands in the timeframe necessary to minimize the number of preventable hemorrhagic deaths is probably not realistically achievable for most healthcare facilities in the United States. Alternative approaches to treat hemorrhage are likely necessary to solve this problem.

Author Biographies

James R. Stubbs, MD

Department of Laboratory Medicine and Pathology, Division of Transfusion Medicine, Mayo Clinic Rochester, Minnesota

Donald H. Jenkins, MD

Department of Surgery, Division of Trauma, UT Health, San Antonio, Texas


Spinella PC, Cap AP: Prehospital hemostatic resuscitation to achieve zero preventable deaths after traumatic injury. Curr Opin Hematol. 2017; 24: 529-535.

Jiaquan X, Murphy SL, Kochanek KD, et al.: Deaths: Final data for 2016. Natl Vital Stat Rep. 2018; 67(5): 1-76.

Ben-Ishay O, Mitaritonno M, Catena F, et al.: Mass casualty incidents--time to engage. World J Emerg Surg. 2016; 11: 8.

Sylvester RD, FitzGerald W, Trivisonno W, et al.: Disaster management. In: Fung MK, Grossman BJ, Hillyer CD, et al. (eds.): Technical Manual, 18th ed. Bethesda, Maryland: AABB; 2014: 97-115.

Doughty H, Glasgow S, Kristoffersen E: Mass casualty events: Blood transfusion emergency preparedness across the spectrum of care. Transfusion. 2016; 56: S208-S216.

Ramsey G: Blood component transfusions in mass casualty events. Vox Sanguinis. 2017; 12: 648-659.

Berwick D, Autumn D, Cornett E, et al., eds.: A national trauma care system: Integrating military and civilian trauma systems to achieve zero preventable deaths after injury. Washington: National Academies Press; 2016.

Spinella PC: Zero preventable deaths after traumatic injury: An achievable goal. J Acute Care Surg. 2017; 82(Suppl 1): S2-S8.

Fox CJ, Bowman JN: Advances in resuscitation in the setting of vascular injury. Perspect Vasc Surg Endovasc Ther. 2011; 23(2): 112-116.

Tien HC, Spencer F, Tremblay LN, et al.: Preventable deaths from hemorrhage at a Level I Canadian trauma center. J Trauma. 2007; 62: 142-146.

Sauaia A, Moore FA, Moore EE, et al.: Epidemiology of trauma deaths: A reassessment. J Trauma. 1995; 38: 185-193.

Cayten CG, Stahl WM, Agarwal N, et al.: Analyses of preventable deaths by mechanism of injury among 13,500 trauma admissions. Ann Surg. 1991; 214: 510-521.

Holcomb JB, Jenkins D, Rhee P, et al.: Damage control resuscitation: Directly addressing the early coagulopathy of trauma. J Trauma. 2007; 62: 307-310.

Glasgow S, Davenport R, Perkins Z, et al.: A comprehensive review of blood product use in civilian mass casualty events. J Trauma Acute Care Surg. 2013; 75: 468-474.

Dann EJ, Bonstein L, Arbov L, et al.: Blood bank protocols for large-scale civilian casualty events: Experience from terrorist bombing in Israel. Transfus Med. 2007; 17: 135-139.

Dann EJ, Michaelson M, Barzelay M, et al.: Transfusion medicine during the summer of 2006: Lessons learned in northern Israel. Transfus Med Rev. 2008; 22: 70-76.

Soffer D, Klausner J, Bar-Zohar D, et al.: Usage of blood products in multiple-casualty incidents. The experience of a level I trauma center in Israel. Arch Surg. 2008; 143: 983-989.

Gorlin JB, Hick JL: Minneapolis bridges falling down: Emergency transfusion preparedness. Transfus Apher Sci. 2013; 49: 403-407.

Bala M, Kaufman T, Keidar A, et al.: Defining the need for blood and blood products transfusion following suicide bombing attacks on a civilian population: A level I single Centre experience. Injury. 2014; 45: 50-55.

Nollet KE, Ohto H, Yasuda H, et al.: The great east Japan earthquake of March 11, 2011, from the vantage point of blood banking and transfusion medicine. Transfus Med Rev. 2013; 27: 29-35.

Akkok C: The Oslo blood bank, 22 July 2011. Tidsskr Nor Laegeforen 2011; 131: 2460-2461.

Li Z, Wang W, Chen T: Blood transfusion therapy for 41 earthquake casualties. Transfus Apher Sci. 2009; 41: 179-181.

Alarhayem AQ, Myers JG, Dent D, et al.: Time is the enemy: Mortality in trauma patients with hemorrhage from torso injury occurs long before the “golden hour.” Am J Surg. 2016; 212: 1101-1105.

Lerner EB, Moscati RM: The golden hour: Scientific fact or medical “urban legend”? Acad Emerg Med. 2001; 8: 758-760.

Cowley RA, Hudson F, Scanlan E, et al.: An economical and proved helicopter program for transporting the emergency critically ill and injured patient in Maryland. J Trauma Acute Care Surg. 1973; 13: 1029-1038.

Cowley RA: A total emergency medical system for the State of Maryland. MD State Med J. 1975; 24: 37-45.

Sampalis JS, Lavoie A, Williams JL, et al.: Impact of on-site care, prehospital time, and level of in-hospital care on survival in severely injured patients. J Trauma. 1993; 34: 252-261.

Pepe P, Wyatt CH, Bickell WH, et al.: The relationship between total prehospital time and outcome in hypotensive victims of penetrating injuries. Ann Emerg Med. 1987; 16: 293-297.

Newgard CD, Schmicker RH, Hedges JR, et al.: Emergency medical services interval and survival in trauma: assessment of the “golden hour” in a North American prospective cohort. Ann Emerg Med. 2010; 55: 235-246.

Carr BG, Kaplan JM, Pryor JP, et al.: A meta-analysis of prehospital care times for trauma. Prehosp Emerg Care. 2006; 10: 198-206.

Harmsen A, Giannakopoulos GF, Moerbeek PR, et al.: The influence of prehospital time on trauma patients outcome: A systematic review. Injury. 2015; 46: 602-609.

Feero S, Hedges JR, Simmons E, et al.: Does out-of-hospital EMS time affect trauma survival? Am J Emerg Med. 1995; 13: 133-135.

MacKenzie EJ: Review of evidence regarding trauma system effectiveness resulting from panel studies. J Trauma Acute Care Surg. 1999; 47: S34-S41.

Morrison JJ, Oh J, DuBose JJ, et al.: En-route care capability from point of injury impacts mortality after severe wartime injury. Ann Surg. 2013; 257: 330-334.

Kotwal RS, Howard JT, Orman JA, et al.: The effect of a golden hour policy on the morbidity and mortality of combat casualties. JAMA Surg. 2016; 151: 15-24.

Eastridge BJ, Mabry RL, Seguin P, et al.: Death on the battlefield (2001-2011): Implications for the future of combat casualty care. J Trauma Acute Care Surg. 2012; 73: S431-S437.

Butler FK Jr, Hagmann J, Butler EG: Tactical combat casualty care in special operations. Mil Med. 1996; 161(suppl): 3-16.

Kotwal RS, Montgomery HR, Mechler KK: A prehospital trauma registry for tactical combat casualty care. U.S. Army Med Dep J. 2011; 11(3): 15-17.

Eastridge BJ, Mabry RL, Blackbourne LH, et al.: We don’t know what we don’t know: Prehospital data in combat casualty care. U.S. Army Med Dep J. 2011: 11-14.

Kotwal RS, Montgomery HR, Kotwal BM, et al.: Eliminating preventable death on the battlefield. Arch Surg. 2011; 146: 1350-1358.

Kelly JF, Ritenour AE, McLaughlin DF, et al.: Injury severity and causes of death from Operation Iraqi Freedom and Operation Enduring Freedom: 2003-2004 vs 2006. J Trauma. 2008; 64(suppl): S21-S27.

Karl A, Pham T, Yanosky JD, et al.: Variability of uncrossmatched blood use by helicopter EMS programs in the United States. Prehosp Emerg Care. 2016; 20(6): 688-694.

Midwinter MJ: Damage control surgery in the era of damage control resuscitation. J R Army Med Corps. 2009; 155: 323-326.

Brohi K, Singh J, Heron M, et al.: Acute traumatic coagulopathy. J Trauma. 2003; 54: 1127-1130.

Davenport R, Khan S: Management of major trauma haemorrhage: Treatment priorities and controversies. Br J Haematol. 2011; 155: 537-548.

Spahn DR, Bouillon B, Cerny V, et al.: Management of bleeding and coagulopathy following major trauma: An updated European guideline. Crit Care. 2013; 17: R76.

Bodnar D, Rashford S, Hurn C, et al.: Characteristics and outcomes of patients administered blood in the prehospital environment by a road based trauma response team. Emerg Med J. 2014; 31: 583-585.

Gerhardt RT, Strandenes G, Cap AP, et al.: Remote damage control resuscitation and the Solstrand Conference: Defining the need, the language, and a way forward. Transfusion. 2013; 53(suppl 1): 9S-16S.

Jenkins D, Stubbs J, Williams S, et al.: Implementation and execution of civilian remote damage control resuscitation programs. Shock 2014; 41(Suppl 1): 84-89.

Bjerkvig CK, Strandenes G, Eliassen HS, et al.: “Blood failure” time to view blood as an organ: How oxygen debt contributes to blood failure and its implications for remote damage control resuscitation. Transfusion. 2016; 56(Suppl 2): S182-S189.

Jenkins DH, Rappold JF, Badloe JF, et al.: Trauma hemostasis and oxygenation research position paper on remote damage control resuscitation: definitions, current practice, and knowledge gaps. Shock. 2014; 41: 3-12.

The CRASH-2 Collaborators, Roberts I, Shakur H, et al.: The importance of early treatment with tranexamic acid in bleeding trauma patients: An exploratory analysis of the CRASH-2 randomised controlled trial. Lancet. 2011; 377: 1096-1101.

Strategies to enhance survival in active shooter and intentional mass casualty events: A compendium. Am Coll Surg Bull. 2015; 100(1S): 53-55.

Jacobs LM, Eastman A, McSwain N, et al.: Improving survival from active shooter events: The Hartford Consensus. Bull Am Coll Surg. 2015; 100: 32-34.

Butler FK: Military history of increasing survival: The U.S. military experience with tourniquets and hemostatic dressings in the Afghanistan and Iraq conflicts. Bull Am Coll Surg. 2015; 100: 60-64.

Chesser TJ, Cross AM, Ward AJ: The use of pelvic binders in the emergent management of potential pelvic trauma. Injury. 2012; 43(6): 667-669.

U.S. Department of Justice, Federal Bureau of Investigation: A Study of Active Shooter Incidents in the United States Between 2000 and 2013. Washington, DC: Washington Navy Yard; September 16, 2013.

Bjelopera J, Bagalman E, Caldwell S, et al.: Public mass shootings in the United States: Selected implications for federal public health and safety policy (Congressional Research Service Report R43004). Available at Accessed February 12, 2019.

Gani F, Sakran J V, Canner JK: Emergency department visits for firearm-related injuries in the United States, 2006-14. Health Aff. 2017; 36(10): 1729-1738.

Smith ER, Shapiro G, Sarani B: The profile of wounding in civilian public mass shooting fatalities. J Trauma Acute Care Surg. 2016; 81: 86-92.

Champion HR, Bellamy RF, Roberts CP, et al.: A profile of combat injury. J Trauma. 2003; 54: S13-S19.

Belmont PJ Jr, McCriskin BJ, Sieg RN, et al.: Combat wounds in Iraq and Afghanistan from 2005 to 2009. J Trauma Acute Care Surg. 2012; 73: 3-12.

Smith ER, Shapiro G, Sarani B: Fatal wounding pattern and causes of potentially preventable death following the Pulse Night Club shooting event. Prehosp Emerg Care. 2018; 22: 662-668.

Shackelford SA, del Junco DJ, Powell-Dunford N, et al.: Association of prehospital blood product transfusion during medical evacuation of combat casualties in Afghanistan with acute and 30-day survival. JAMA. 2017; 318: 1581-1591.

Tisherman SA, Schmicker RH, Brasel KJ, et al.: Detailed description of all deaths in both the shock and traumatic brain injury hypertonic saline trials of the Resuscitation Outcomes Consortium. Ann Surg. 2015; 261: 586-590.

Mulcahy AW, Kapinos KA, Briscombe B, et al.: Toward a sustainable blood supply in the United States: An analysis of the current system and alternatives for the future. Santa Monica, CA: RAND, 2016.

Borkent-Raven BA, Janssen MP, Van Der Poel CL: Demographic changes and predicting blood supply and demand in the Netherlands. Transfusion. 2010; 50: 2455-2460.

Drackley A, Newbold KB, Paez A, et al.: Forecasting Ontario’s blood supply and demand. Transfusion. 2012; 52: 366-374.

Tinegate H, Pendry K, Murphy M, et al.: Where do all the red blood cells (RBCs) go. Results of a survey of RBC use in England and North Wales in 2014. Transfusion. 2015; 56: 139-145.

Klein HG, Hrouda JC, Epstein JS: Crisis in the sustainability of the U.S. blood system. N Engl J Med. 2017; 377: 1485-1488.

Ellingson KD, Sapiano MRP, Haass KA, et al.: Continued decline in blood collection and transfusion in the United States--2015. Transfusion. 2017; 57(suppl 2): 1588-1598.

Simonetti A, Hussein E, Walderhaug M, et al.: An inter-regional US blood supply simulation model to evaluate blood availability to support planning for emergency preparedness and medical countermeasures. Disaster Med Public Health Preparedness. 2018; 12: 201-210.

Hirshberg A, Stein M, Walden R: Surgical resource utilization in urban terrorist bombing: A computer simulation. J Trauma. 1999; 47: 545-550.

Abir M, Davis MM, Sankar P, et al.: Design of a model to predict surge capacity bottlenecks for burn mass casualties at a large academic medical center. Prehosp Disaster Med. 2013; 28: 23-32.

Kauvar DS, Lefering R, Wade CE: Impact of hemorrhage on trauma outcome: An overview of epidemiology, clinical presentations, and therapeutic considerations. J Trauma. 2006; 60(suppl 6): S3-S11.

Johnstone DJ, Evans SC, Field RE, et al.: The Victoria bomb: A report from the Westminster Hospital. Injury. 1993; 24: 5-9.

Peral-Gutierrez de Ceballos J, Turégano-Fuentes F, Perez-Diaz D, et al.: The terrorist bomb explosions in Madrid, Spain--An analysis of the logistics, injuries sustained and clinical management of casualties treated at the closest hospital. Crit Care. 2005; 9: 104-111.

AABB: Disaster operations handbook. Coordinating the nation’s blood supply during disasters and biological events. Version 2.0. Bethesda, MD, AABB, 2008. Available at

Propper BW, Rasmussen TE, Davidson SB, et al.: Surgical response to multiple casualty incidents following single explosive events. Ann Surg. 2009; 250: 311-315.

Shinar E, Yahalom V, Silverman BG: Meeting blood requirements following terrorist attacks: the Israeli experience. Curr Opin Hematol. 2006; 13: 452-457.

Lozada MJ, Cai S, Li M, et al.: The Las Vegas mass shooting: an analysis of blood component administration and blood bank donations. J Trauma Acute Care Surg. 2019; 86: 128-133.

Federal Emergency Management Agency National Exercise Division: 1 October After-Action Report. Washington, DC: FEMA, August 24, 2018.

Harasim P, Munks J: Las Vegas-area hospitals like “war zones” after Strip massacre. Las Vegas Review-Journal. 2017. Available at

Smith J, Simpson G, Heightman A: EMS response to the mass shooting at the Route 91 Harvest Festival in Las Vegas. Available at Accessed February 19, 2019.

American Red Cross: Red Cross Statement on Las Vegas Shooting. Published October 2017. Available at Accessed February 19, 2019.

Glasgow S, Vasilakis C, Perkins Z, et al.: Managing the surge in demand for blood following MCI: Early automatic restocking may preserve red cell supply. J Trauma Acute Care Surg. 2016; 81: 50-57.

Hayes C: FBI: More active shooting incidents in 2017 than any other year recorded. USA Today, May 4, 2018.

Bjerkvig CK, Strandenes G, Eliassen HS, et al.: “Blood failure” time to view blood as an organ: How oxygen debt contributes to blood failure and its implications for remote damage control resuscitation. Transfusion. 2016; 56: S182-S189.

White NJ, Ward KR, Pati S, et al.: Hemorrhagic blood failure: Oxygen debt, coagulopathy, and endothelial damage. J Trauma Acute Care Surg. 2017; 82(Suppl 1): S41-S49.

Stubbs JR, Zielinski MD, Berns KS, et al.: How we provide thawed plasma for trauma patients. Transfusion. 2015; 55: 1830-1837.

Stubbs JR, Zielinski MD, Jenkins D: The state of the science of whole blood: Lessons learned at Mayo Clinic. Transfusion. 2016; 56: S173-S181.

Stubbs JR, Tran SA, Emery RL, et al.: Cold platelets for trauma-associated bleeding: Regulatory approval, accreditation approval, and practice implementation--just the “tip of the iceberg.” Transfusion 2017; 57: 2836-2844.

Kaada SH, Apelseth TO, Gjerde Hagen K, et al.: How do I get an emergency civilian walking blood bank running? Transfusion 2019; 59: 1446-1452.



How to Cite

Stubbs, MD, J. R., and D. H. Jenkins, MD. “Blood Transfusion Preparedness for Mass Casualty Incidents: Are We Truly Ready?”. American Journal of Disaster Medicine, vol. 14, no. 3, Aug. 2019, pp. 201-18, doi:10.5055/ajdm.2019.0332.



Review Articles

Most read articles by the same author(s)