Page 42 - JSOM Winter 2018

solution)—administered in large volumes as the initial resusci-
tation fluid, followed at a later point in time by the transfusion
of blood components as indicated by laboratory testing—be-
came popularized for treating patients in hemorrhagic shock,
despite the lack of evidence for the safety and efficacy of this
change. 62,63 A quote from COL Andre Cap sums up the par-
adox of asanguinous fluids being used as the preferred fluid
for initial resuscitation of patients in hemorrhagic shock: “The
historic role of crystalloid and colloid solutions in trauma re-
suscitation represents the triumph of hope and wishful think- FIGURE 1 Whole blood—
ing over physiology and experience.” 63 the best option for
resuscitation fluid on
the battlefield.
The 1993 Battle of Mogadishu in Somalia documented the use
and efficacy of whole blood in the modern era. The conflicts
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in Iraq and Afghanistan saw a resurgence of the use of whole
blood for treating casualties in hemorrhagic shock. The use
of whole blood was initially spurred by logistical constraints Photo courtesy Dr Phil Spinella.
in delivering stored blood components, particularly platelets,
to forward-deployed surgical teams, necessitating the use
of “walking blood banks.” The beneficial effects of whole
blood have been documented in research done by a number
of individuals and organizations throughout the recent war LTOWB for use in combat casualties and recommended mak-
years. 52,63,65-70 The 2014 CoTCCC review of the fluid options ing medics and austere surgical teams a priority for receiving
for resuscitating casualties in hemorrhagic shock found that LTOWB. However, LTOWB remains in limited supply across
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the optimal fluid to use was whole blood. A recent paper ex- the battlefield and is not reliably available in the prehospital
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amined the impact of a number of factors on prehospital death phase of care for all casualties who need emergent resuscita-
in combat fatalities and found that the odds of KIA mortality tion for hemorrhagic shock.
were 83% lower in casualties who needed prehospital blood
transfusion and received that intervention. Pivalizza and col- Stopping the Bleed in Abdominopelvic NCTH
30
leagues note that “During the course of combat trauma care in
recent Iraq and Afghanistan campaigns, fresh WB has become There are presently several interventions designed to control
a cornerstone of resuscitation.” 62 abdominopelvic NCTH that are either available or currently
being developed. The first is the Abdominal Aortic Junctional
The American Association of Blood Banks recently endorsed Tourniquet (AAJT), a pneumatic device that applies external
the concept of using Low Titer Type O Whole Blood (LTOWB) pressure to the abdomen through the use of a pneumatic blad-
as universal donor whole blood. Their recommendation for der. 75-78 This device has been shown to effectively occlude the
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resuscitation of patients in hemorrhagic shock states: “Recipi- aorta at the level of the bifurcation. The two primary con-
ents shall receive ABO group-compatible Red Blood Cell com- cerns with the AAJT device are: 1) if the NCTH bleeding site
ponents, ABO group-specific Whole Blood, or low titer group is above the level of the aortic bifurcation, this device may
O Whole Blood (for nongroup O or for recipients whose ABO actually increase bleeding; and 2) ischemia of the tissues distal
group is unknown).” The 31st edition of the standards goes on to the occlusion site. 78
to indicate that the definition of “low titer” shall be made lo-
cally by each transfusion service, and that the transfusion ser- Even though teams with an ARC capability will have the abil-
vice must have a policy specifying which patients are eligible ity to do Focused Assessment with Sonography in Trauma
to receive WB, the maximum quantity of WB per patient, and (FAST) exams to assess for intra-abdominal bleeding, a nega-
how to monitor for potential adverse events post-transfusion tive FAST exam does not completely exclude the possibility of
(standard 5.27.1). Figure 1 depicts a unit of LTOWB—the intra-abdominal bleeding. A study of 413 combat casualties
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resuscitation fluid of choice in ARC. suspected of having suffered intra-abdominal injury found
that while the specificity of FAST for intra-abdominal injury
The Southwest Texas Regional Advisory Council for Trauma, was 98%, sensitivity was only 56%. The patients in this
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serving 22 counties over 26,000 square miles in Texas, has now study were not necessarily hypotensive, which would likely
made O+ cold-stored LTOWB its prehospital resuscitation fluid lower the sensitivity of the FAST exam in comparison to ex-
of choice for trauma patients meeting transfusion criteria. ams performed on patients with abdominopelvic hemorrhage
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The group considered the impact of using Rh+ blood on female severe enough to produce hypotension.
patients of childbearing age. In 30 months, there was only one
female patient of childbearing age who met the criteria for the Aortic occlusion by both REBOA and the AAJT also entails
massive transfusion protocol, leading to the decision that O+ the risk of cardiopulmonary arrest when safe aortic occlusion
Type O Low Titer whole blood was safe and would best serve times are exceeded and the blood flow to—and from—dis-
the needs of the community. The decision to use prehospital tal tissues is restored. Kheirabadi reported that 3 of 6 spon-
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LTOWB was also made by the Harris County (Texas) EMS taneously breathing pigs suffered a cardiopulmonary arrest
District #48 and Cypress Creek EMS in August of 2017. 73 when the AAJT was removed after a 2-hour application during
which the aorta was occluded just above the bifurcation (which
A recent Joint Trauma System (JTS) review of trauma care in would mirror the occlusion in Zone 3 REBOA). The authors
the US Central Command noted the increased availability of attributed these events to ischemia-induced hyperkalemia and

40 | JSOM Volume 18, Edition 4 / Winter 2018