Low titer group O whole blood resuscitation: Military experience from the point of injury

Abstract

INTRODUCTION In the far forward combat environment, the use of whole blood is recommended for the treatment of hemorrhagic shock after injury. In 2016, US military special operations teams began receiving low titer group O whole blood (LTOWB) for use at the point of injury (POI). This is a case series of the initial 15 patients who received LTOWB on the battlefield. METHODS Patients were identified in the Department of Defense Trauma Registry, and charts were abstracted for age, sex, nationality, mechanism of injury, injuries and physiologic criteria that triggered the transfusion, treatments at the POI, blood products received at the POI and the damage-control procedures done by the first surgical team, next level of care, initial interventions by the second surgical team, Injury Severity Score, and 30-day survival. Descriptive statistics were used to characterize the clinical data when appropriate. RESULTS Of the 15 casualties, the mean age was 28, 50% were US military, and 63% were gunshot wounds. Thirteen patients survived to discharge, one died of wounds after arrival at the initial resuscitative surgical care, and two died prehospital. The mean Injury Severity Score was 21.31 (SD, 18.93). Eleven (68%) of the causalities received additional blood products during evacuation/role 2 and/or role 3. Vital signs were available for 10 patients from the prehospital setting and 9 patients upon arrival at the first surgical capable facility. The mean systolic blood pressure was 80.5 prehospital and 117 mm Hg (p = 0.0002) at the first surgical facility. The mean heart rate was 105 beats per minute prehospital and 87.4 beats per minute (p = 0.075) at the first surgical facility. The mean hospital stay was 24 days. CONCLUSION The use of cold-stored LTOWB at POI is feasible during combat operations. Further data are needed to validate and inform best practice for POI transfusion. LEVEL OF EVIDENCE Therapeutic study, level V.

An analysis of outcomes for pediatric trauma warm fresh whole blood recipients in Iraq and Afghanistan

“…More recent data from the combat theaters may help address this gap as the use of LTOWB has permeated both major theaters of operations and into the prehospital setting. [28][29][30][31] There are several limitations to this study. First, the data presented are observational and retrospective, thus we are unable to assess the effects of blood administration on mortality beyond associations.…”

Hemorrhagic shock and hemostatic resuscitation in canine trauma

“…80,81 More recently, the military reported on the use of low titer O whole blood administered to wounded service members near the point of injury and demonstrated encouraging results as to the feasibility of this product in resourcelimited environments. 82 After adopting chilled whole blood for helicopter emergency medical transports, a major US urban trauma center reported excellent feasibility and promising mortality results. 83 In addition, transfusing whole blood for severely injured people has reduced mortality by two fold as well as reduced the need for blood products by 53% when compared to transfusions with either red cells or plasma or both.…”

“…Two studies have shown that the addition of fresh whole blood to resuscitation protocols improved mortality and decreased bleeding in severely wounded military personnel 80,81 . More recently, the military reported on the use of low titer O whole blood administered to wounded service members near the point of injury and demonstrated encouraging results as to the feasibility of this product in resource‐limited environments 82 . After adopting chilled whole blood for helicopter emergency medical transports, a major US urban trauma center reported excellent feasibility and promising mortality results 83 .…”

Prehospital resuscitation

“… 11 Whole blood is now the preferred resuscitative fluid of the CoTCC 3 and despite the challenges associated with temperature requirements, cold stored LTOWB has been effectively transported to and used in austere military environments 12 with favorable results shown in a case series. 13 Civilian experience with prehospital whole blood transfusion is still limited. One regional program has been established in Texas and although mortality data has not been published the cost–benefit balance seems to be favorable.…”