Page 27 - Journal of Special Operations Medicine - Fall 2014

medical personnel, but the principles of DCR apply to was associated with 30-day survival that was similar to
53
this phase of care as well insofar as DCR is achievable 1:1:1 component therapy in 107 patients. A review of
in the far-forward environment. The fluid options for 1745 patients with major trauma (age 18 to 45 years, ISS
prehospital resuscitation from hemorrhagic shock are greater than 25, and received blood transfusions) from
discussed next. the 2009 National Trauma Data Bank found that pa-
tients who were treated with blood component therapy
DCR With Whole Blood were 3.2 times more likely to die than were those treated
Whole blood replaces coagulation factors and platelets, with whole blood (p = .010). 59
reverses intravascular volume deficit, and restores oxy-
gen-carrying capability. It is noteworthy that, with the Although FWB collected in emergent circumstances in
advent of the capability to fractionate whole blood into the theater is not screened to the same extent as would
components, there was very limited evidence (especially be the case in routine blood banking practice and there-
in trauma patients) that component therapy was equiva- fore is not US Food and Drug Administration (FDA)
lent to whole blood transfusion in the treatment of hem- compliant, the Assistant Secretary of Defense For Health
orrhagic shock in trauma patients. 51–53 As non–whole Affairs has recognized the possible need to use noncom-
blood transfusion regimens began to come into use and pliant blood products in deployed medical settings and
crystalloid was used with more frequency as part of the defined the procedures that must be followed to ad-
resuscitation, the complications of trauma-associated dress typing considerations and infection surveillance
53
60
coagulopathy, ARDS, and ACS became more frequent. for noncompliant blood products. The Joint Trauma
Although 1:1:1 plasma:RBC:platelet component ther- System Clinical Practice Guideline (CPG) on FWB states
apy is an attempt to approximate whole blood, these that FWB is indicated only when “. . . other blood prod-
components as used in 1:1:1 resuscitation are anemic, ucts are unable to be delivered at an acceptable rate to
coagulopathic, and thrombocytopenic in comparison to sustain the resuscitation of an actively bleeding patient,
whole blood. 54,55 Elmer and colleagues note that 1:1:1 when specific stored components are not available (e.g.,
component therapy yields a combined transfusion prod- RBCs, platelets, cryo, thawed plasma), or when stored
uct with an approximate hematocrit of 29%, a platelet components are not adequately resuscitating a patient
count of 85,000/μL, and approximately 60% of normal with an immediately life-threatening injury.” The JTTS
61
56
clotting activity. Any crystalloid or colloid used in the Damage Control CPG notes that FWB is “at least equiv-
resuscitation further increases the severity of the iatro- alent to component therapy and at best is independently
49
genic coagulopathy through hemodilution. associated with improved survival.” This guidance is
further supported by the findings of Perkins and coau-
In a retrospective study of 488 casualties, improved thors who compared the transfusion of platelets as ei-
survival was noted when FWB was used in addition to ther FWB or apheresis platelets in massive transfusion
PRBCs and plasma (common practice when platelets combat trauma patients and found similar outcomes. 62
were not available), compared with the administration
57
of RBCs and FFP without platelets or FWB. In a ret- Noting that crystalloids and colloids add weight and bulk
rospective study of 354 combat casualties, Spinella and to the medic’s kit and that their use may result in resus-
coauthors found that 100 casualties treated with RBCs, citation injury (including acidosis, hypothermia, ARDS,
plasma, and warm FWB (but not apheresis platelets) had ACS, and dilutional coagulopathy), Strandenes and his
a higher 30-day survival rate (95% versus 82%) than did colleagues and others have called for increased empha-
254 casualties treated with RBCs, plasma, and apheresis sis on far-forward blood transfusion programs. 63–66 Far-
58
platelets (but not FWB). Cold storage may extend the forward FWB transfusions have been successfully carried
maximum storage period for whole blood, prompting out during the conflicts in Iraq and Afghanistan, and
a call for prospective trials of resuscitation with whole protocols have been developed to enable this interven-
blood compared with component therapy. One study tion to be safely used by advanced capability providers
51
of 591 massively transfused combat casualties found an trained to perform it. 64,65,67 Far-forward blood is hardly a
association between warm fresh whole blood transfusion new concept—there is a case report of its successful use
and a higher incidence of acute lung injury, but it was to treat a British casualty in shock in the trenches during
noted that warm FWB was administered preferentially to World War I. New cold storage and pathogen reduc-
68
more severely injured patients, thus raising the possibil- tion techniques may also enable whole blood to be safely
ity that the severity of the wounds rather than the FWB stored for longer periods and thus increase its availability
50
was responsible for the higher incidence of lung injury. 58 for use in farther forward treatment locations. An ef-
fective general pathogen reduction system would reduce
A single-center randomized trial in a civilian setting the screening requirements currently used to prevent
found modified whole blood (non–platelet-sparing leuko - transfusion-transmitted diseases and protect blood sup-
69
reduction followed by the addition of apheresis platelets) plies against emerging and nonviral pathogens. Hooper

Fluid Resuscitation for Hemorrhagic Shock in TCCC 19