Best practices on blood and blood products for a prehospital hemorrhage protocol: consensus from the 2025 Canadian prehospital transfusion summit.

BACKGROUND

Blood transfusion is increasingly recognized as a critical component of prehospital resuscitation. However, Canada's vast geography, environmental extremes, and regional variation in health systems present unique challenges to standardized implementation of prehospital hemorrhage protocols (PHPs). The 2025 Canadian Prehospital Transfusion Summit (CPTS), convened by the Canadian Prehospital and Transport Transfusion (CAN-PATT) network, sought to develop consensus-driven best practices for prehospital transfusion strategies across diverse transport environments.

METHODS

A structured roundtable consensus process was held at CPTS 2025, bringing together over 50 subject matter experts from eight provinces, six different services/systems and a variety of operational roles to discuss the past, present and future direction of out-of-hospital blood transfusion in Canada. Key domains included: activation criteria, prioritization of blood components and adjuncts, product logistics, and rural/remote applicability. Recommendations were synthesized through iterative discussion, evidence review, and thematic analysis. Each recommendation was then voted upon until consensus was reached through all participants.

RESULTS

Consensus was reached on core components of a national PHP. Red blood cells and tranexamic acid were identified as foundational therapies. Freeze-dried plasma and whole blood offer logistical and clinical advantages, particularly in rural and remote areas, while fibrinogen concentrate and prothrombin complex concentrate are valuable adjuncts when plasma is unavailable. Calcium supplementation and active hypothermia prevention were emphasized as essential. Barriers to implementation included short product shelf-life, storage infrastructure, and regulatory constraints. The group recommended development of a standardized Canadian prehospital transfusion dataset and national data registry.

CONCLUSIONS

The panel produced 12 consensus statements based on the available evidence and expert opinion including activation criteria, prioritization of blood products and adjuncts, product logistics, and rural/remote applicability. These consensus statements establish the basis for safe and effective PHP practices in Canada.