Page 18 - Journal of Special Operations Medicine - Spring 2014

application of pressure bandages to the other wounds. After administration of the first unit of 500mL of whole
The wounded Soldier remained under cover from enemy blood, the patient’s tachycardia decreased from 150
fire until a security element repulsed an attack and al- beats/min to 125 beats/min, his femoral pulse became
lowed for evacuation to the outpost aid station. palpable, and his GCS score improved to 15.

The injured Soldier arrived at the remote Level 1 aid sta- The FWB collection was performed using a standard
tion with a delay of 6 hours from the time of injury due blood collection bag containing citrate phosphate dex-
to ongoing enemy activity. He presented with cool, pale trose (CPD) anticoagulant. After venipuncture with a
skin, a Glasgow Coma Scale (GCS) score of 13 (eye re- 16-gauge needle, the donor was bled until the bag was
sponse 4, motor response 5, verbal response 4), a patent filled to approximately 450mL. The blood collection
airway, tachypnea, tachycardia (pulse of 150 beats/min), bag was immediately connected to the peripheral IV line,
and hypotension with only a carotid pulse palpable. and the blood was infused via gravity into the patient.
The patient was monitored closely with vital signs every
Initial attempts to obtain large-bore intravenous (IV) ac- 10 minutes and direct observation from the healthcare
cess were unsuccessful, requiring the use of a sternal in- provider. The donor increased his fluid intake and was
traosseous (IO) device for initiation of hypotensive fluid observed for signs and symptoms of hypovolemia, such
resuscitation with 500mL of Hextend colloid solution as dizziness, hypotension, confusion, and tachycardia—
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per Tactical Combat Casualty Care (TCCC) protocol. none of which were detected.
With no clinical response to the first bolus of Hextend ,
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an additional 500mL was administered in an attempt Approximately 30 minutes after the completion of the
to treat the patient’s hypovolemia. While the colloid so- first unit of whole blood, the patient’s vital signs and
lution was administered, the treatment team addressed mental status deteriorated to a heart rate of 150 beats/
other aspects of the patient’s care. The tourniquet was min and a GCS score of 13. When the decompensation
assessed and found to be effective with no palpable dis- was recognized, an additional unit of blood was col-
tal pulses or significant bleeding from the wound. The lected and administered using the same technique as the
fractured leg was evaluated and resplinted. All wounds initial collection and administration. With continued
were dressed, his pain was managed with IV morphine observation after the second unit of FWB transfusion,
titrated to effectiveness while observing his respiratory the patient’s vital signs deteriorated again after 30 min-
efforts, and a Hypothermia Prevention and Manage- utes, necessitating another unit of FWB collection and
ment Kit (HPMK) was used. After 2 hours of observa- administration. A total of 5 units of FWB were trans-
tion, the Soldier’s pulse rate or GCS score did not show fused to the patient with a similar clinical response after
significant improvement. each transfusion. On administration of the fifth unit,
a CH47 Chinook Helicopter arrived at the outpost to
The critical nature of the casualty’s injuries was dis- transport the patient to the nearest forward surgical
cussed with the on-scene commander. A medical evacu- team (FST).
ation platform would not be available until the tactical
situation permitted. A numerically superior enemy force When the patient was finally evacuated, approximately
continued to occupy the surrounding high-ground, which 15 hours after sustaining his injuries, the vital signs re-
posed a catastrophic threat to any attempt at aeromedi- corded by the flight medic were a GCS score of 15, alert
cal evacuation. The estimated time for the medical evac- and oriented, blood pressure of 58/24 mm Hg, and a
uation platform was 14 hours after the initial injury of pulse rate of 136 beats/min. After a flight time of ap-
the patient—8 hours after arriving at the remote aid sta- proximately 10 minutes, the patient arrived at the near-
tion. The delay of medical evacuation to a higher level est FST. His vital signs on arrival to the FST were a GCS
of care required alternative methods of fluid resuscita- score of 15, alert and oriented, blood pressure of 75/12
tion to prevent the casualty from developing irreversible mm Hg, and a pulse rate of 140 beats/min.
shock and coagulopathy. This delay led to the consid-
eration of performing an FWB transfusion. The remote After a rapid evaluation, the patient was immediately
aid station did not store packed red blood cells, plasma, prepared for the operating room. An exploratory
or platelets. A “buddy transfusion” was initiated us- laparatomy was performed with identification of isch-
ing type-specific blood based on identification tags and emic bowel, of “old blood” in the peritoneum, and of
verbal confirmation with donor and recipient. The aid diffuse retroperitoneal bleeding. The patient went into
station had neither the capability to perform ABO test- cardiac arrest during the laparotomy, and aggressive at-
ing nor the use of rapid screening tests for infectious tempts at resuscitation were not successful. The patient’s
disease detection that are routinely used at Level 2 and time of death was pronounced at 22:35 Local, 16 hours
3 facilities. after the injury occurred. The autopsy report declared

10 Journal of Special Operations Medicine Volume 14, Edition 1/Spring 2014