Page 113 - JSOM Fall 2018

Resuscitation donor and recipient to be sure that groupings are
correct; if the wrong blood group is transfused, there
Goal: Optimize fluid resuscitation to treat and reverse hemor­ is a possibility of fatal transfusion reaction).
rhagic shock effectively. Fluid resuscitation principles in PFC ■ ■ If adequate staff or supplies not available or in cha­
are the same as TCCC. Blood products are strongly preferred, otic situations, use group O for any patient (possibil­
and every effort should be made to ensure the capability to ity of transfusion reaction if not titer tested; however,
transfuse blood products is available near the point of injury. less likely to result in acute hemolytic transfusion re­
Survival is improved when blood products are transfused action than mistaken group­specific transfusion).
within about 30 minutes of injury. 27

The resuscitation products of choice for casualties in hemor­ Note: If blood-group testing has not been performed on the casualty
rhagic shock, listed from most to least preferred, are: before receiving LTOWB, it may not be possible to establish the under-
lying blood group and they should only receive universal donor blood
■ ■ Whole blood products. Every effort should be made to obtain a blood sample for later
■ ■ Plasma, red blood cells (RBCs), and platelets in a typing before transfusion of LTOWB.
1:1:1 ratio When WB cannot be obtained, resuscitation using blood products
■ ■ Plasma and RBCs in a 1:1 ratio should proceed according to the order of priority for fluid administra-
■ ■ Plasma or RBCs alone tion, targeting an equal balance of all blood products that are available
■ ■ Crystalloid (lactated Ringer’s or Plasma­Lyte A [Baxter, (RBCs, plasma, platelets).
https://www.baxter.com/]).
Transfusion notes:
Caution: Crystalloids or Hextend are therapies of last resort and can ■ ■ If time and staffing permit, utilize rapid TTD test kits
worsen coagulopathy and bleeding. They should be used only in severely when prescreened donors are not available. Priority
bleeding patients with no radial pulse when no blood products are avail-
able. Every effort should be made through training and preparation to for testing should be for HIV and/or any disease of
ensure availability of stored blood products and ability to draw FWB. high significance in local area for which test kits are
available.
Use of Whole Blood During Resuscitation ■ ■ During resuscitation, blood products and fluids should
be warmed using a fluid warmer and infused rapidly.
WB products listed from most to least preferred: ■ ■ WB can be collected and transfused as warm, fresh
o Best: Low­titer group O whole blood (LTOWB) for all whole blood (WFWB) or cold­stored whole blood
■ ■ Food and Drug Administration–compliant LTOWB (CS­WB). CS­WB will almost always be LTOWB. See
supplied by the Armed Services Blood Program. WB CPG for more details. 28
■ ■ LTOWB drawn from prescreened donors at deployed ■ ■ WFWB may have some advantages for resuscitation
location, either before mission or during combat ca­ in the PFC environment when prescreened donors are
sualty care. available and the tactical situation allows, because
– Identify LTOWB donors before deployment. Test WFWB may be associated with improved survival in
all personnel with group O blood for anti­A and trauma patients. 3,4,29 However, CS­WB is more com­
anti­B antibodies; low titer is defined as immuno­ pletely tested for infectious disease and does not require
globulin M anti­A and anti­B ratio less than 1:256. additional personnel to collect or donate the blood,
– Test for transfusion transmitted diseases (TTDs) and should be used preferentially when available.
before deployment and maintain a roster of ■ ■ Blood and blood products should only be admin­
donors while deployed. Repeat TTD testing every istered by personnel who are trained in the proper
90 to 120 days when possible. procedure and the identification and management of
■ ■ If adequate staff available, confirm ABO group of transfusion reactions.
LTOWB donor prior to transfusing patient using El­ ■ ■ Usually only one unit of FWB should be collected per
don card or other approved ABO testing kit. If the donor. However, in extremis, two units may be taken
wrong blood group is transfused, there is a possibil­ from a single donor. Depending on the size and phys­
ity of fatal transfusion reaction. ical fitness of the donor, a two­unit collection may
o Better: Administer group­specific WB from prescreened degrade the tactical performance of a donor, whereas
donors a single unit collection will not. If a second unit is
■ ■ Group A to group A, group O to group O and collected from the same donor, consider evacuating
LTOWB for group B and group AB. the donor with the casualty.
■ ■ Group specific for all ABO Group ■ ■ Freeze­dried plasma (FDP) may be administered to ini­
■ ■ The ABO group of the patient must be confirmed us­ tiate resuscitation while obtaining FWB and/or moving
ing Eldon card or other approved ABO testing kit. If the casualty to a location where blood products are
the wrong blood group is transfused, there is a possi­ available. The indications to give FDP are the same as
bility of fatal transfusion reaction. the indications for transfusion. FDP is a universal blood
o Minimum: when prescreened donors for LTOWB or product that can be given to any blood group group.
group­specific WB are not available, identify unscreened ■ ■ See Appendix A for a summary of blood products
donors using an Eldon card or other approved ABO test­ provided by the Armed Services Blood Program.
ing kit. If the need arises to use blood from unscreened
donors, see Appendix B. Hemostatic Adjuncts
■ ■ Group specific (if adequate staff are available, per­
form testing and verify with second round of test­ Goal: Use medications to optimize the casualty’s ability to
ing; i.e., two Eldon cards by two providers for both form blood clots.

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