Page 90 - JSOM Winter 2019

Prehospital Whole Blood in SOF

Current Use and Future Directions

Thomas B. Jones, 18D; Virgil L. Moore, 18D; Akira A. Shishido, MD*

ABSTRACT
The US Joint Trauma System (JTS) recommends stored whole require expanded distribution and standardization of “blood
blood (SWB) as the preferred product for prehospital resusci- kits.” Additionally, SOF medical planners must put greater
tation of battlefield casualties in both their Tactical Combat emphasis on education and the importance of WB over crys-
Casualty Care (TCCC) guidelines and their clinical practice talloids or colloids—as many medics continue to carry only
guidelines (CPGs). Clinical data from nearly 2 decades of war these products out of convenience. As SOF strive to establish
during Operation Iraqi Freedom (OIF) and Operation Endur- tactics, techniques, and procedures (TTPs) and streamline pre-
ing Freedom (OEF) suggest that whole blood (WB) is safe, ef- hospital WB delivery, we must constantly reassess and refine
fective, and far superior to crystalloid and colloid resuscitation our procedures, incorporate the latest evidence and technol-
fluids. The JTS CPG for whole blood transfusion reflects the ogy, and adapt to an evolving battlefield.
most recent clinical evidence but poses unique challenges for
execution by Special Operations Forces (SOF) operating in Keywords: prehospital; whole blood; executive summary
austere environments. Given the limited shelf-life of 35 days,
WB requires a constant steady pool of donors. Additionally,
the cold-chain requirement for storage poses challenges for Introduction: WB as a Standard of Care
SOF on long missions without access to blood refrigerators.
SOF operating in less-developed theaters face additional lo- The JTS recommends SWB as the preferred product for prehos-
gistical challenges. To mitigate the challenges of WB delivery, pital resuscitation of battlefield casualties both in their TCCC
US SOF have implemented various protocols to ensure op- guidelines and their CPGs. The JTS CPG for whole blood
1
timal donor pool, awareness/education among medics and transfusion reflects the most recent clinical evidence but also
specialized equipment for tactical methods of blood-carry stems from extensive historical wartime use and tactical advan-
and delivery. In general, steps taken include the following: tages. However, the CPG poses unique challenges for execution
(1) Prior to deployment, soldiers are screened for blood type by SOF operating in austere environments. To address these
and titers in order to establish a large donor pool. Support challenges, current US SOF have implemented various TTPs,
soldiers have been found to be particularly beneficial donors although widespread implementation will require standardiza-
as they typically are in closer proximity to the blood support tion, resourcing, and education for homogeneity. Additionally,
detachment. (2) In units that operate in smaller teams, such as units should constantly reassess these TTPs based on outcome

ODAs, medics are outfitted with “blood kits” to carry blood to optimize their processes and adapt to an evolving battlefield.
on missions for point of injury transfusion. In units with larger
teams, LTOWB donors are identified on missions and deliver Background
fresh WB in the event of casualties. (3) Medics receive a WB
transfusion refresher tabletop exercise and review after action SWB is drawn from a human donor and stored in an anticoag-
reviews from previous rotations. Additionally, prehospital WB ulant solution: citrate-phosphate-dextrose (CPD) for 21 days
delivery is a required component of scenario-based premission or CPD-adenine (CPDA-1) for up to 35 days when cooled
training. The expectation is that medics will administer WB to 1°C to 6°C. After collection, the Armed Services Blood
on missions when tactically feasible. Using the prolonged field Program (ASBP) tests these units for transfusion transmitted
1
care framework (ruck, truck, house) as a template, medics diseases. Because SWB is collected, stored, and tested by a
now use different methods to store and transport the SWB de- licensed center, it is US Food and Drug Administration (FDA)
1
pending on phase. Medic “truck” and “house” kits include the approved for use in battlefield casualties. FWB is typically
™
Dometic CFX powered coolers that run on AC, DC, or solar drawn in emergency situations (aka “walking blood bank”)
power and allow for constant temperature monitoring. When when there is not an adequate supply of SWB or other resus-
on foot, medics have been outfitted with tactical blood coolers citative products. FWB is drawn and administered at room
1,2
™
including the Pelican Biomedical Medic 4 or Combat Medi- temperature within 24 hours and therefore is not tested for
cal Blood Box along with a Belmont Buddy-Lite intravenous TTD and is not FDA approved.
™
™
(IV) infusion warmer and IV administration kit with standard
micron filter. Presently, SOF medics have the donor support, Low-titer O WB (LTOWB) refers to type O blood that has
logistical framework, training, and equipment to deliver WB at <1:256 saline dilution of anti-A and anti-B antibody titers. Spe-
the point of injury. However, widespread implementation will cifically, IgM is more closely associated with hemolysis than
*Correspondence to akira.shishido@socom.mil
SFC Jones, SFC Moore, and MAJ Shishido are affiliated with 2nd BN 1SFG(A).
88