Page 125 - JSOM Summer 2020

Fresh Whole Blood Collection and Transfusion at Point of Injury,
Prolonged Permissive Hypotension, and Intermittent REBOA

Extreme Measures Led to Survival in a Severely Injured Soldier—A Case Report

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Clayton J. Lewis, MD *; Matthew Nilan, DO ; Charles Srivilasa, MD ; Ryan Knight, MD ;
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Joseph Shevchik, DO ; Brad Bowen, ATP ; Ty Able, ATP ; Peter Kreishman, MD 8
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ABSTRACT
We present the case of a severely injured Special Operations Case Presentation
Servicemember whose care was remarkable for three unique
interventions: the first use of a walking blood bank performed While conducting combat operations in Afghanistan, a 33-
at the point of injury, prolonged permissive hypotension, and year-old active duty Ranger sustained a right-sided complex
intermittent resuscitative endovascular balloon occlusion of blast injury from an improvised explosive device.
the aorta (REBOA).
The Ranger’s injuries included massive soft tissue injury from
the right costal margin to the right knee, right internal iliac
Keywords: resuscitative endovascular balloon occlusion of vein injury, right femoral head/neck fractures with significant
the aorta (REBOA); intermittent REBOA; permissive hypo- bone loss, right pelvis destruction (both column right ace-
tension; walking blood bank; buddy transfusion
tabular fractures, comminuted ilium fracture with complete
disruption of the sacroiliac joint, superior/inferior pubic rami
fractures bilaterally), sigmoid colotomy, bilateral pneumotho-
races, and mangled right upper extremity (RUE) with arterial
Introduction
injuries to the brachial, radial, and ulnar arteries. His Injury
Since 2014, tactical combat casualty care (TCCC) guidelines Severity Score was 66 (Figure 1).
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have advocated for early resuscitation with whole blood, and
several studies have shown a survival benefit in trauma with At point of injury, the Ranger medics immediately placed tour-
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whole blood transfusion. In 2018, Advanced Resuscitative niquets on the right upper and lower extremities, while an im-
Care (ARC) was introduced to supplement TCCC guidelines. provised pelvic binder with a junctional tourniquet device was
Based on the mortality associated with noncompressible torso inflated over the right groin. Constant manual pressure to the
hemorrhage and a gap in prehospital measures to control casualty’s right groin and abdomen was maintained through-
this, ARC promotes early whole blood administration and out the entire treatment process. IV access was established in
REBOA. 4 the left antecubital fossa and 1g of TXA was rapidly admin-
istered. Needle decompressions were performed in all four
Walking blood banks (WBBs), or the emergent collection and authorized sites with the addition of a right-sided chest tube
transfusion of fresh warm whole blood, is a well-established (Figure 2). A total of 4 units of cold stored low-titer O whole
contingency in current combat operations at established lev- blood (CSWB) was administered to the casualty with the trans-
els of care. The most forward recorded WBB was during a fusion target of a palpable radial pulse. Due to ongoing hemor-
well-coordinated assault on a small combat outpost where a rhage, deteriorating mental status, the depletion of all CSWB,
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provider orchestrated a WBB at his aid station. Numerous and the inability to immediately evacuate the casualty because
Special Operations organizations have protocols in place for of ongoing enemy engagements, the Ranger group O low-titer
far forward WBBs. 6–10 Until recently, there have been no re- (ROLO) WBB was initiated. Three units of fresh warm group
corded reports of a WBB performed at the point of injury. O low-titer blood were collected from prescreened, co-located
Rangers while the unit was actively engaged on target. Once
We will be presenting a case of a severely injured Ranger who collected, 2 units, along with calcium gluconate, were trans-
received fresh whole blood at the point of injury. In addition, fused awaiting medical evacuation. During evacuation to the
this severely injured Servicemember’s care was remarkable for forward resuscitative surgical team (FRST), an additional unit
intermittent REBOA and prolonged prehospital permissive collected on target was transfused followed by two additional
hypotension, ultimately leading to the patient’s survival. units of CSWB from the CASEVAC aircraft.
*Correspondence to clayton.j.lewis4.mil@mail.mil
1 MAJ Lewis is affiliated with Evans Army Community Hospital, Fort Carson, CO. MAJ Nilan is affiliated with Evans Army Community
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Hospital, Fort Carson, CO. MAJ Srivilasa is affiliated with C-STARS, St. Louis, MO. LTC Knight is affiliated with 1/75th Ranger Regiment.
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5 CPT Shevchik is 1/75th Ranger Regiment Battalion Surgeon. SSG Brad Bowen is affiliated with 1/75th Ranger Regiment. SGT Able is affiliated
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with the 1/75th Ranger Regiment. LTC Kreishman is affiliated with Madigan Army Medical Center, Joint Base Lewis-McChord, WA.
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