Page 47 - JSOM Winter 2018

Point of care or emergency department lactate measurement of Anti-A and Anti-B antibody titers as part of the
is being increasingly recognized as a way to identify trauma pre screening process, utilize untitered Type O units of
patients in whom anaerobic metabolism has begun to occur whole blood as the third option. 123
and in whom lifesaving interventions are more likely to be re- d. If there is a unit-based WBB designed to collect, type,
quired. 108,109,113,116,117 In a prospective 2008 study of 124 patients and transfuse type-specific whole blood, that is a fourth
who required emergency transport and had SBPs of 100 or be- option. 124
low, Jansen et al noted that individuals with a prehospital lac- *NOTE: Option (d) may result in morbidity or even death
tate (performed at the time of ambulance arrival at the scene) of due to ABO mismatch if the wrong blood type is transfused.
3.5mmol/L or higher, had a significantly higher mortality (41%) *NOTE: 1:1 Type O RBCs and plasma should be used in the
than those with a lactate level of 3.4 or lower (12%). Guyette suboptimal circumstance that FDA-compliant whole blood is
115
and colleagues noted that a threshold POI lactate of 2.5mmol/L not available, but FDA-compliant red blood cells and plasma
had the same specificity for predicting the need for resuscitative are available. 125
care as an SBP of 90mmHg or less (48%). They noted further *NOTE: Use of non–FDA-compliant whole blood requires
that there was a linear association of POI lactate and the need additional post-transfusion monitoring per DoD directives.
for resuscitative care in the range of 2.5 to 3.9mmol/L, and that e. Continue resuscitation until an SBP of 80–90mmHg is
beyond a threshold value of 4.0mmol/L, higher POI lactates present.
were not associated with further increases in the need for re- f. If the casualty has an altered mental status due to sus-
suscitative care. In their review of POI lactate measurement, pected TBI, resuscitate as necessary to restore and main-
108
Lewis and colleagues noted that all of the patients in the 2015 tain a target SBP of at least 90mmHg.
Guyette study who required resuscitative care had a POI lac- g. During resuscitation, blood products should be warmed
tate greater than 3.4mmol/L. The Southwest Texas Regional using a fluid warmer and infused rapidly.
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Advisory Council chose a prehospital lactate of 5mmol/L or h. As whole blood transfusion is being performed, con-
greater as an indication for prehospital blood transfusion. sider obtaining early common femoral artery access so
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that REBOA can be undertaken quickly after the first
Additionally, many combat casualties have Traumatic Brain unit of whole blood has been administered should the
Injury (TBI) as well as NCTH. The presence of prehospital casualty subsequently be found to meet the criteria for
hypotension has been shown to increase mortality in casual- REBOA.
ties with TBI. The use of point-of-care lactate measurements
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may allow identification of patients with ongoing NCTH be- Whole blood has been previously identified as the preferred
fore they become hypotensive and thus increase survival in the resuscitation fluid in TCCC for casualties in hemorrhagic
subset of casualties with both NCTH and TBI. Many point- shock. 31,33,50 In the previously mentioned case series by North-
of-care lactate monitoring devices are FDA-approved for use ern et al, the authors noted that in caring for their 20 crit-
in monitoring the level of anaerobic metabolism in athletic ically injured casualties, they transfused 128 units of whole
events. Two devices that have been FDA-approved for use as blood (57% of blood products transfused). Their paper stated
medical devices are the Lactate Pro 2 (Arkray) and the Stat- that: “It is the opinion of the authors that all patients requir-
Strip (Nova Biomedical). 118,119 The i-Stat device (Abbot) also ing damage control resuscitation should be treated with only
includes lactate measurement in its capabilities. 120 whole blood (Low Titer O Whole Blood) and/or FWB) when
massive transfusion is anticipated.” Resuscitation should be
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Compensatory Reserve Measurement is a technology in devel- initiated with FDA-compliant, cold-stored LTOWB as the pre-
opment that may also improve early identification of occult ferred option and every effort should be made to have cold-
hemorrhage in casualties with NCTH by detecting the pres- stored LTOWB available. FDA-complaint LTOWB is now
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ence of significant loss of intravascular volume through con- being shipped from the US and distributed across the battle-
tinuous analysis of arterial pulse waveform before there is an field in the US Central Command. The logistics of cold-stored
observed decrease in systolic blood pressure. 110,121 At present, whole blood carriage are a challenge for ground medics, al-
however, a device that has been proven to accurately and reli- though small portable containers capable of maintaining cold
ably measure the compensatory reserve in an austere environ- storage conditions for up to 72 hours without power are now
ment is not commercially available. available. Teams with an ARC capability should have access to
larger capacity passive cold-storage blood storage containers
Whole Blood Transfusion Procedure in ARC or actively cooled containers. 126
Individuals performing whole blood resuscitation in ARC
should follow the JTS Damage Control and Whole Blood Although cold-stored, FDA-compliant LTOWB is the first
CPGs except as follows: choice for whole blood resuscitation when logistically feasible,
there are other options for obtaining whole blood on the bat-
*TCCC-Specific Considerations: tlefield. The 75th Ranger Regiment has pioneered a unit-based
a. Resuscitation should be initiated with FDA-compliant WBB in which all members of the unit are typed, screened
Cold-Stored Low Titer Type O+ Whole Blood (LTOWB) for transfusion-transmitted pathogens, and have anti-A and
as the preferred option and every effort should be made anti-B immunoglobulin (IgM) levels quantitated. Those with
to have cold-stored LTOWB available. 71,122 an IgM titer < 256 are considered to be universal donors. 91,127
b. LTOWB from a unit-based, pre-screened and pre-titered When whole blood is needed to transfuse casualties in the pre-
walking blood bank (WBB) should be used as the sec- hospital phase of care, blood is collected from the universal
ond option if FDA-compliant cold-stored LTOWB is not donors for this purpose. Fresh, Type O, low-titer whole blood
available. 91 from unit-based, pre-screened and pre-titered WBBs should
c. If there is a unit based, pre-screened WBB designed to col- be used as the second option if FDA-compliant cold-stored
lect whole blood but that does not include quantification LTOWB is not available.

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