Page 59 - Journal of Special Operations Medicine - Winter 2014

conflict zones, it is possible that, due to extended lines of medics, which is based on US SME consensus opinion,
communication, traditionally accepted military medical rather than on evidence-based studies.
evacuation timelines from point of wounding will be re-
quired to flex beyond the current 1-, 2-, and 4-hour rules
adopted by NATO or the 60-minute window used by the Study
US military. In conflict zones where infrastructure is lim- McLennan recently undertook a study reviewing 2500
9
ited or the threat to military medical assets is significant, hospitalized casualties from the Defence Medical Services
there is potential for medics to be operating in support Joint Theatre Trauma Register. These records were exam-
of troops with little or no immediate clinical TACEVAC ined to identify the physical injuries and physiological signs
capability. For these medics, many of whom are likely to that were most predictive of the need for massive blood
be working in the Special Forces community or support- transfusion in battlefield casualties arriving at a Role 3
ing expeditionary deployments, there is a requirement hospital. This study was able to derive a combination of
to develop the capability for giving blood products. The physical injuries and physiological signs that were highly
ability to give products to casualties allows operational predictive of the need for massive blood transfusion, and
flexibility both in terms of stabilizing casualties to allow this tool has the potential to aid planning of blood prod-
extraction distant from the point of wounding and for re- uct requirements for Role 3 and Damage Control Surgical
ducing mortality in patients with significant hemorrhage (DCS) facilities in future theaters of operation. Within the
before or during subsequent TACEVAC. data set used in the hospital study were 476 patients for
whom prehospital observations data were complete.
As manufacturers strive to develop reconstituted blood
products that can be carried forward, robust tools should The authors examined the subset of prehospital data to
be developed to ensure any administration is appropri- identify physical injuries and physiological parameters
ate. Informal discussions with members of deployed US that were highly predictive of the need for massive blood
and UK Special Forces CASEVAC, TACEVAC, and de- transfusion. In conjunction with current thinking regard-
ployed Role 3 senior clinicians have supported the con- ing the timing, appropriateness, and volume of blood
cept and requirement for medics to take reconstituted product transfusion in the prehospital setting, we sought
blood products forward in future areas of operations but to determine the significance and specificity of the cur-
all are mindful of the indications for their appropriate rent DUSTOFF guidelines for the administration of blood
use. Corpsmen (US) and Combat Medical Technicians products during evacuation to a medical facility.
(UK), who might be making the decision to administer
these products in the absence of a physician, have wel-
comed the development of a simple scoring system to Methods
assist them. For the physicians supporting a prehospital Data for analysis were taken from the UK Joint The-
emergency care system and its personnel, there must be atre Trauma Registry (JTTR). Patients are included in
an inherent protective “umbrella” that allows the medic this database if they or someone else in the same inci-
to operate with a high degree of accuracy remote from dent are the subject of a trauma call on arrival at the
immediate senior clinical advice. To this end, any scor- field hospital or if they are evacuated to the UK Role
ing system must be simple to use and have a very high 4 Hospital as a result of their injuries. Children aged
degree of specificity and a high level of sensitivity to be 16 or younger were excluded from this study. Prehospi-
of benefit. tal data are rarely fully recorded in the military setting
due to the difficulties of obtaining and completing this
To the experienced practitioner, it is often apparent information during an ongoing military operation. 10,11
whether to administer blood products. Relying, however, The JTTR was searched for patients who presented to
on a “clinical acumen” approach risks issues associated the hospital between 15 January 2007 and 12 July 2010
with interobserver variability. In resource-constrained en- and for whom both pulse and SBP had been recorded in
vironments, unnecessary administration may compromise the prehospital phase of their treatment.
the ability to transfuse future casualties, but awareness
of this creates reluctance to use resources. The challenge On arrival at the Role 3 hospital, a trained trauma nurse
in designing a simple scoring system is to identify highly coordinator (TNC) recorded clinical data prospectively
predictive indicators that together offer the best level of onto trauma charts. At the conclusion of the patient epi-
sensitivity and specificity on which to base the tool. sode, all clinical information including that recorded in
the prehospital phase is collated by the TNC and re-
A review of the literature does not identify any preexist- corded retrospectively onto the JTTR. To identify cases
ing tools developed to help distinguish patients who may where massive blood transfusion had been required, the
require blood products at the point of wounding. There authors defined two distinct criteria relating to the tim-
is, however, a guideline currently used by US DUSTOFF ing and volume of blood products given: “acute blood

When to Administer Blood Products in Aeromedical Evacuation 49