Page 58 - Journal of Special Operations Medicine - Winter 2014

Predicting When to Administer Blood Products
During Tactical Aeromedical Evacuation:

Evaluation of a US Model

Simon Le Clerc, MB ChB, FCEM, DMCC, DIMC RCSEd, RGN, REMT-P, RAMC;
Jackie McLennan, MB ChB, FCEM, MRCSEd(A&E), FCEM;
Anthony Kyle, MA (Ed), RN, PMRAFNS; Elizabeth Mann-Salinas, PhD, RN; Rob Russell, MD

ABSTRACT
The administration of blood products to battlefield aid at the point of wounding. The focus of this initial
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casualties in the prehospital arena has contributed sig- battlefield first aid is to recognize and address any cata-
nificantly to the survival of critically injured patients strophic hemorrhage before managing airway, breathing,
in Afghanistan over the past 5 years. Given as part and noncatastrophic circulatory issues. On arrival of ro-
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of an established military “chain of survival,” blood tary TACEVAC assets, patients are able to receive trans-
product administration has represented a step-change fusion of warmed blood products while on route to the
improvement in capability for both UK and US tacti- hospital. Rapid administration of packed RBCs (PRBCs)
cal aeromedical evacuation (TACEVAC) platforms. The and FFP has contributed to the increased survival and re-
authors explore current concepts, analyzing and explor- duced morbidity relating to the conflict in Afghanistan.
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ing themes associated with early use of blood products On occasion, administration of PRBCs and FFP to pa-
(fresh frozen plasma [FFP] and red blood cells [RBCs]), tients in traumatic cardiac arrest on arrival of the Medical
and they compare and evaluate a US/UK study analyz- Emergency Response Team (MERT) has contributed to a
ing the differences and recommending future strategy. restoration of cardiac output on the casualty’s arrival at
The subject matter expert (SME) consensus guidelines the Role 3 field hospital. As a result of military experi-
developed for use by the US Army Air Ambulance units ence, blood products (PRBCs and FFP) are recognized as
commonly known as call sign “DUSTOFF.” These the prehospital fluids of choice in major trauma and are
TACEVAC assets in Afghanistan were validated in this in the process of adoption in the United Kingdom by sev-
retrospective study. Using statistical analysis, the au- eral Helicopter Emergency Medical Services (HEMS) in
thors were able to ascertain that the current DUSTOFF preference over crystalloid, starch, or colloid solutions. 3
SME–derived guidelines offer a sensitivity of 63.04%
and a specificity of 89.07%. By adjusting the indicators Bodnar et al. demonstrated that early transfusion of
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to include a single above-ankle amputation with a sys- blood products offers a proportion of hypovolemic
tolic blood pressure (SBP) less than 90mmHg and pulse trauma patients an advantage in terms of survival. In

greater than 120/min, the sensitivity could be increased addition to restoration of circulating blood volume to
to 67.39% while maintaining the specificity at 89.07%. poorly perfused tissues, blood products help to mitigate
In our data set, a single amputation above the ankle, in trauma-associated coagulopathy. Blood transfusion is
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combination with an SBP of less than 100mmHg and a not without risk, however, and can place a casualty in
pulse of greater than 120/min, increased the sensitivity jeopardy through the transmission of blood-borne vi-
to 76% but with a slight drop in specificity to 86%. Fur- ruses, immune modulation, transfusion-related acute
ther study of military prehospital casualty data is under lung injury (TRALI), and compatibility problems. Ad-
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way to identify additional physiological parameters that ditionally, inappropriate over transfusion places recipi-
will allow simple scoring tools in the remote setting to ents at increased risk from complications. 7
guide the administration of prehospital blood products.
As the conflict in Afghanistan draws down, there is a
Keywords: trauma, prehospital, blood products, military, danger that much hard-won military medical corporate
scoring tool, tactical, aeromedical evacuation memory and lessons learned will be lost. Amid the myr-
iad of advances in trauma management, the future use
of forward blood and blood products provides logistical
challenges in terms of both supply and administration.
Introduction
Despite these challenges, the emerging evidence continues
Before evacuation, severely wounded casualties receive to support the benefits of early blood product transfusion
immediate “buddy-aid” and, if available, emergency first in physiologically shocked trauma patients. In future
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