Page 126 - JSOM Summer 2020

inflation, slowing his hemorrhage significantly. He received
36 units PRBCS, 36 units FFP, 4 units apheresis platelets, and
30 units cryoprecipitate. A WBB was initiated and transfusion
was switched to FWB. He received an additional 8 units of
FWB. His left lower extremity (LLE) became mottled without
FIGURE 1. Mangled distal signals. In addition to daily operations for contamina-
right upper extremity with tion control and continued soft tissue debridement, he was
tourniquet in place. There
were multiple injuries to the taken to the OR for thrombectomy of the left infragenicular
brachial, radial, and ulnar popliteal artery and four-compartment fasciotomy. A comple-
arteries, prohibiting shunt tion angiogram demonstrated minimal but present flow via
placement and salvage of his posterior tibial artery. Anticoagulation and thrombolysis
extremity.
were considered at this point but the patient’s continued hem-
orrhage and coagulopathy made the risk of antithrombotic
therapy prohibitive. He developed transfusion associated cir-
culatory overload (TACO) resulting in significant pulmonary
edema and high mechanical ventilation requirements, but he
improved gradually with diuresis and aggressive ventilator
management. As a preemptive measure, the extracorporal
membrane oxygenation (ECMO) team from the San Antonio
Military Medical Center (SAMMC) was mobilized to trans-
port the patient back to the US. However, his pulmonary sta-
FIGURE 2. Extensive soft tus improved, and he did not require ECMO cannulation. He
tissue injuries extending was placed on continuous renal replacement therapy (CRRT)
from the right costal
margin to the right thigh. for potassium management given anticipated long transport
time that was continued throughout his flight.

The soldier arrived to SAMMC on postinjury day 3. His LLE
was found to be ischemic with no distal signals. He was taken
for LLE angiogram, popliteal artery thrombectomy, and poste-
At the FRST, he arrived in extremis with a faintly palpable rior tibial thrombectomy. On postinjury day 34, he underwent
carotid pulse. Massive transfusion was begun with CSWB and LLE below the knee amputation and right hemipelvectomy. He
blood components. The WBB was initiated; 47 units of type has returned to the operating room for multiple debridements
specific fresh whole blood (FWB) were collected, and 26 units of his large soft tissue injuries, and at the time of this writing, his
were transfused. Total blood transfusion requirements at the wounds have all been covered with autografts. He is extubated,
FRST were 16 units PRBCs, 6 units FFP, 1 unit apheresis plate- alert, and progressing through his rehabilitation process. He has
lets, 10 units CSWB, and 26 units FWB. Based on the patient’s normal neurologic function with no cognitive impairments.
pattern of injury, a Zone 3 REBOA was placed for continued
hemodynamic support. The right common femoral artery was Discussion
exposed in the zone of injury and noted to be dissected on
inspection. As a result, the REBOA catheter was placed via the During the past decade, the use of FWB collected from WBBs
left common femoral artery under ultrasound guidance. The has increased in current combat theaters. The benefit seen with
patient was taken for damage control surgery including pack- prehospital whole blood transfusions has led to numerous or-
ing of his iliac vein injury, exploration of RUE vasculature, ex- ganizations implementing protocols for far forward medical
ploratory laparotomy with sigmoid colon repair, debridement personnel to collect and perform a WBB. The ROLO protocol
of devitalized soft tissue, and extensive packing of massive soft is the first recorded case of a WBB performed at POI. The use
tissue wounds with hemostatic gauze. Due to the extent of the of FWB at POI is obvious in the case of this severely injured
RUE vascular injuries which made shunting impossible, the patient, and it has implications for future combat operations.
tourniquet was left in place for transfer to Role 3. The REBOA In particular, FWB collection/donation may be necessary in
was deflated intermittently with no more than 45 minutes of scenarios of prolonged field care where evacuation to higher
occlusion time during any period. The total REBOA time was levels of care is delayed/impossible and in environments where
110 minutes. The deflated REBOA was left in place during cold chain storage and blood resupply is immature or nonex-
evacuation to the next level of care (Role 3). Our ER physi- istent. There is evidence that Soldiers who donate 1 unit of
cian, trained in REBOA, accompanied the patient in transport whole blood during combat operations are not significantly
and transfused an additional 5 units of FWB during the flight. negatively impacted by the donation. 11–13 In this case, all three
donors immediately returned to the fight and continued with-
At the Role 3, the patient underwent a right transhumeral am- out degradation in physical abilities.
putation (deemed nonsalvageable given the massive soft tissue
loss, contamination, extensive vascular injury, and ongoing Advocated in TCCC guidelines and the damage control resus-
shock), repair of his right internal iliac vein, right hip disartic- citation clinical practice guideline, permissive hypotension is
ulation, approximation of pelvis bone fragments, and further based on the principle of reducing dilutional coagulopathy and
debridement of soft tissue. The left femoral arterial sheath was decreasing hydrostatic pressure and the dislodging of micro-
removed. In the ICU, he had ongoing massive hemorrhage, ne- vascular clots. Despite its widespread use, the evidence for per-
cessitating placement of a new REBOA sheath/catheter (again missive hypotension is heterogeneous with many confounding
through the left common femoral artery) with 30 minutes of variables like environments of care (prehospital vs in-hospital),

124 | JSOM Volume 20, Edition 2 / Summer 2020