Page 48 - JSOM Winter 2018

Another option for a walking blood bank capability is to use Whole blood should be warmed during transfusion. A recent
a simpler and less expensive process to identify potential FWB review of battery-powered blood warmers found that the War-
donors. Approximately 40% of the US population is Type O rior device (QinFlow, Tel-Aviv, Israel) performed better than
and, in the event of a mass casualty, these individuals could be the Buddy Lite and the Thermal Angel. 132
called upon to serve as universal donors without the expensive
additional step of quantifying their Anti-A and Anti-B titers. As Bjerkvig and colleagues have recently examined the question
noted in the 2013 paper by Nessen, despite the extensive use of transfusion speed when using sternal interosseous devices
of untitered Type O whole blood during World War II, there as compared to peripheral intravenous access. 450mL of
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were no reports of the intravascular hemolytic transfusion reac- autologous blood was collected from volunteers and rein-
tions (IHTR) typical of the transfusion reactions caused by high fused (along with 63mL of CPDA-1) using either an 18-gauge
Anti-A and Anti-B titers until 1944, when a few incidents were peripheral IV, the Tactically Advanced Lifesaving IO Needle
noted. 123,128 These episodes of IHTR did not cause any fatalities, (T.A.L.O.N.) or the FAST1 IO. There were 10 subjects in each
but did result in a subsequent US policy of screening Type O do- group. The reinfusion was accomplished with gravity alone,
nors for Anti-A and Anti-B titers. Those found to have high titers without the use of pressure infusers. The median reinfusion
were excluded from serving as “universal donors.” Nessen de- rate was found to be 32.4mL/min in the T.A.L.O.N. group,
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scribed the use of FWB in 94 patients, 51% of whom received 46.2mL/min in the FAST1 group, and 74.1mL/min in the in-
type-specific FWB and 49% that received uncross-matched Type travenous group. There was no evidence of hemolysis resulting
O FWB. The authors concluded that: “Mortality was similar for from the procedure. The authors noted that the FAST1 group,
patients transfused uncross-matched Type O FWB compared had 1 (9%) failure in 11 procedures, whereas the T.A.L.O.N.
with ABO type-specific FWB in an austere setting. Further stud- group had 4 (29%) of 14 procedures fail. The authors’ con-
ies evaluating outcomes related to the use of uncross-matched clusion was that peripheral IV access is preferable if it can
Type O FWB in these settings are warranted.” 123 be obtained, but that IV access is often problematic in bleed-
ing casualties and that the sternal IO route is an acceptable
Type specific fresh whole blood drawn from a walking blood alternative.
bank is standard massive transfusion practice for US Role 2 fa-
cilities. The paper by Miller et al describes the mass casualty As whole blood transfusion is being accomplished, the pro-
130
incident that was managed by the surgical team aboard the vider should be aware of the need to prepare for REBOA
USS Bataan. The ship carried 20 units of Type O PRBCs and should it appear likely that this further intervention will be
124
8 units of frozen plasma to support its embarked Role 2 capa- needed to stabilize the casualty. It is helpful to obtain common
bility. In addition, however, the ship’s crew and embarked Sail- femoral artery access before SBP drops to a level that makes
ors and Marines are also considered potential blood donors. the procedure more difficult. A recent paper by Matsumura
It is the practice of Navy casualty-receiving ships to transfuse noted that “Moreover, since the difficulty in obtaining arterial
type-specific FWB, not fresh LTOWB, and 34 units of warm, access increases exponentially according to hemodynamic in-
fresh, type-specific whole blood were obtained and used for 2 stability, the decision to access early influences the subsequent
of the patients cared for by the team on the Bataan. In the Role resuscitation and hemostasis.” 95
2 shipboard setting, blood-typing and transfusion-transmitted
disease testing is performed by a trained laboratory techni- Indications for REBOA in ARC
cian. While this option is feasible, it is clearly a less-desirable The indications for REBOA listed below reflect the indication
124
choice for ARC than either cold-stored or fresh LTOWB be- specified in Appendix B of the Joint Trauma System REBOA
cause of the potential for a potentially fatal major ABO mis- CPG: “SBP < 90 with Transient or No Response to Initial
match, especially when done in the prehospital setting rather ATLS Resuscitation” with additional provisions made for
25
than by a Role 2 surgical team. the prehospital environment.
Cordova published a case report of a critically-injured casu- *TCCC-Specific Considerations:
alty who was treated with type-specific FWB in Afghanistan. a. Relevant Tactical Field Care interventions (external
The casualty did not survive his wounds, but the transfusions hemorrhage control, pelvic binding, and TXA) have
resulted in temporary improvements in his condition. This been accomplished; AND
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option may also be feasible for Special Forces medics, who are b. Advanced monitoring (Electronic blood pressure mea-
taught to use Eldon cards to enable type-specific transfusions surement) has been established; AND
for small Special Forces teams if needed. c. ARC resuscitation has been previously initiated with
whole blood if feasible or other blood products as noted
In summary, the two preferred options for whole blood trans- previously; AND
fusion in ARC are cold-stored, FDA-compliant LTOWB or d. SBP remains < 90mmHg immediately after 1 unit of
fresh LTOWB from a pre-screened and pre-titered walking whole blood or 1 unit each of RBCs and plasma have
blood bank. Untitered Type O FWB entails additional risk been administered as quickly as possible; AND
over a low-titer product, but the risk of reaction is not high e. The casualty has penetrating or severe blunt force in-
and fatal hemolytic reactions are rare. Type specific FWB may jury to the abdomen or pelvis and a positive FAST
be used as a last resort, but a type mismatch using this option exam or is judged to be at high risk for abdominopelvic
carries the risk of potentially fatal hemolytic reaction. NCTH or is noted to have difficult-to-control junctional
hemorrhage.
The latter two options are less desirable, especially when AND
blood-typing is not performed by trained and experienced f. Intrathoracic bleeding and hemopericardium have not
technicians, but may be considered when cold-stored LTOWB been found on bilateral chest tube insertion and chest
or fresh LTOWB donors are not available. ultrasound exam.

46 | JSOM Volume 18, Edition 4 / Winter 2018