Page 19 - Journal of Special Operations Medicine - Spring 2014

the multiple ballistic injuries with significant abdominal measures to control hemorrhage, it can sustain life while
bleeding as the cause of death. 7 awaiting evacuation.

Discussion Disclaimers
An FWB transfusion can be a life-saving or life-prolonging The authors have nothing to disclose.
intervention in the appropriate setting. A combat casu-
alty in hypovolemic shock and coagulopathy with de layed
medical evacuation to a surgical team is an appropriate References
patient to consider for this procedure. While the ulti- 1. Nessen SC, Eastridge BJ, Cronk D, et al. Fresh whole blood
mate outcome was death in this case report, the patient use by forward surgical teams in Afghanistan is associated
arrived to a surgical team 15 hours after his injury, alert with improved survival compared to component therapy
and oriented with a GCS score of 15. In this scenario, without platelets. Transfusion. 2013;53(Suppl):107–113.
FWB transfusion gave this patient the best chance of 2. Spinella PC, Perkins JG, Grathwohl KW, Beekley AC,
Holcomb JB. Warm fresh whole blood is independently
survival.
associated with improved survival for patients with com-
bat-related traumatic injuries. J Trauma. 2009;66:S69–S76.
There is potential for catastrophic side effects when 3. U.S. Army Institute of Surgical Research. Joint Theatre
performing this procedure. The greatest risk is adminis- Trauma System Clinical Practice Guideline—Fresh Whole
tering an ABO mismatch between donor and recipient. Blood Transfusion, 2006.
Rentas et al. reported a 3.7% error rate for blood group 4. Strandenes G, et al. Emergency whole blood use in the
5
documentation on military identification tags in a U.S. field: a simplified protocol for collection and transfusion.
Army garrison setting. This risk should be considered Shock. 2013;December.
and prevented with additional ABO typing for military 5. Rentas FJ, Clark PA. Blood type discrepancies on military
personnel operating in remote locations or on high-risk identification cards and tags: a readiness concern for in the
U.S. Army. Mil Med. 1999;164:785–787.
missions. Any potential for ABO donor–recipient mis- 6. Berséus O, Boman K, Nessen SC, Westerberg LA. Risks of
match should be eliminated when possible.
hemolysis due to anti-A and anti-B caused by the trans-
fusion of blood or blood components contacting ABO-in-
If there is concern regarding the accuracy of the ABO compatible plasma. Transfusion. 2013;53(Suppl):114–123.
type of the donor or recipient, it may be safer to trans- 7. Armed Forces Institute of Pathology, Office of the Armed
fuse whole blood from a type O donor with low anti- Forces Medical Examiner. Autopsy examination report. 18
A and anti-B antibody titers if these titers are known. October 2009.
The risk of a fatal adverse event from ABO mismatch
is much higher from incorrect type-specific transfusion
than from the use of low-titer type O whole blood in a
non–type O recipient. Current Department of Defense CPT Cordova served as a medic in the 25th Infantry Division
6
guidelines advocate the use of only type-specific whole and deployed to Iraq and Afghanistan as a squadron physician
blood transfusions. Furthermore, measurement of anti- assistant in the 2nd Infantry Division, and the 4th Infantry Di-
A and anti-B titers is not commonly performed. More vision, respectively. He currently serves as the orthopedic phy-
sician assistant at Keller Army Community Hospital at West
widespread implementation of remote FWB transfu- Point, New York. He has a bachelor’s of science and a master’s
sions for isolated military units would be facilitated by of physician assistant studies from the University of Nebraska
adoption of a rigorous program of verification and doc- Medical Center. E-mail: christopher.b.cordova.mil@mail.mil.
umentation of blood types and antibody titers before
deployment. LTC Cap trained in internal medicine, hematology, and on-
cology at Walter Reed Army Medical Center, Washington,
Deployed military personnel must adapt their procedures DC. He currently serves as chief of Blood Research at the U.S.
and skills to overcome the challenges of operating in Army Institute of Surgical Research and staff hematologist at
austere environments. Casualties suffering from exsan- the San Antonio Military Medical Center, JBSA-FT Sam Hous-
guinating hemorrhage must be supported until surgical ton, Texas. He specializes in critical care hematology, coagula-
intervention is possible. FWB treats hemorrhagic shock tion disorders, and transfusion medicine. He is an instructor in
the Joint Forces Combat Trauma Management Course and a
by restoring circulating volume and oxygen-carrying hematology consultant for USASOC, the Committee on Tacti-
capacity. It also treats coagulopathy by providing fresh cal Combat Casualty Care, and USAMMDA blood product
platelets and coagulation factors from plasma while development teams.
avoiding the dilutional coagulopathy caused by asan-
guinous fluids. It cannot substitute for surgical inter- Dr. Spinella is the director of the Critical Care Translational
vention indefinitely, but in combination with aggressive Research Program in the Division of Critical Care, Department

Fresh Whole Blood Transfusion in Austere Environment 11