Page 35 - JSOM Summer 2020

manager to meet those requirements, plan for their own WBB, be suitable for small, highly mobile surgical teams or in the
and prepare for contingencies. 13,58 ARSC environment. There is no light, portable, approved plas-
ma-thawing device. Portable water heaters and thermometers
Fresh whole blood (FWB) use in the combat casualty setting can be used to create a 30–37° C bath of water to thaw FFP
is associated with improved survival when compared with and warm PRBCs to the appropriate temperature of 37° C;
administration of packed red blood cells (PRBCs) and fresh however, they are not FDA approved for this use. Approxi-
frozen plasma (FFP) alone. FWB eliminates the need for mately 10% of FFP bags may break during thawing and this
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blood cooling, storage, and rewarming equipment but car- should be factored into the supply. Prethawing frozen plasma
ries increased risk of transmissible disease, and FWB donors saves time in the acute setting, but once thawed, plasma must
may be limited in some operational environments. It is recom- be used within 5 days.
mended, and will be doctrinal in an upcoming DoD Instruc-
tion, that anti-A and anti-B titer levels be collected from all Walking Blood Bank
deploying personnel with type O blood in addition to FDA-
recommended infectious disease testing. This strategy pro- Every ARSC team member must be trained to draw and trans-
vides a constant blood-donor pool for contingencies. For US fuse FWB and must be able to recognize and treat transfusion
casualties, FWB donors should be US personnel, rarely from reactions. Recruitment and blood typing of potential blood
coalition forces, and from local nationals only in the most donors may take time, so early initiation of a WBB is recom-
extreme cases. See the JTS Whole Blood Transfusion CPG mended for patients with the suspected need for massive trans-
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for detailed guidance. Point-of-care testing for some trans- fusion. Fresh whole-blood transfusion must be type specific
mittable diseases exist (e.g., human immunodeficiency virus), unless the donor has been predesignated low-titer type O by
but the required time for interpretation may be prohibitive in laboratory testing. All low-titer type O donors must provide
patients in severe hemorrhagic shock. Have a plan in place for documentation of titer testing before donation. See the “JTS
patients and donors who test positive for such diseases, and Whole Blood Transfusion CPG.” Standard equipment sets
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recognize that there may be significant cultural implications should contain blood-collection kits. Ensure Eldon cards and
with local nationals and partner nation forces who test posi- point-of-care infectious disease testing kits are available and
tive for such diseases. team members are trained in their use. Ensure a reliable sys-
tem for marking and numbering (1) individual donors, (2)
The need to remain light and mobile further increases the chal- blood-donor bags, and (3) Eldon cards.
lenge of retaining an adequate supply of blood products for
mission support. Portable battery-operated blood refrigera- Logistical Considerations
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tors and freezers are available (e.g., HemaCool ) but require
®
mobility platforms to move over long distances, and mechan- Packing for ARSC missions can be framed usefully by the
ical failures in hot and dusty environments may occur. Re- Ruck-Truck-House model developed by SOF medics. This is
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frigerators and freezers require a constant and reliable power a modular approach to mission planning based on cube and
source, further increasing the team’s weight and footprint and weight constraints. As building blocks, each phase of this sup-
reducing maneuverability. Mission requirements for increased ply model builds on the previous phase, with Ruck capabilities
mobility may limit the size and number of refrigeration equip- intrinsic to Truck, and Truck capabilities intrinsic to House.
ment and thus blood availability, and vice versa. The term Ruck-Truck-House refers to the cube and weight
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of the mission equipment and not necessarily to the mobility
PRBCs and frozen plasma are readily available at Role 2, platform. For example, Ruck missions may be performed from
Role 3, and ARSC teams, but supply of platelet components a truck, and Truck missions are often conducted via rotary
is limited despite increasing use of cold-stored platelets. Stored wing platforms.
low-titer type O whole blood and never-frozen liquid plasma
are increasingly available via the ASBP theater blood distribu- Specific team-member composition of each team is based on
tion system. Freeze-dried plasma may be available for some multiple variables, and specific staffing recommendations are
ARSC missions supporting SOF. Options for acquiring blood outside the scope of this practice guideline. Generally, ARSC
outside official supply and resupply channels include WBB teams should be prepared to scale their team size according to
drives (requires blood typing capability such as Eldon cards mission requirements dictated by the Operational Command.
as well as citrate bags) and blood from the local area, such A Ruck team may have the fewest personnel of any given
as local hospitals, for use on host-nation casualties should be ARSC team that still provides a minimal, functional capability,
considered when appropriate. Inform the theater JBPO if con- and a House team may comprise the maximum number of per-
sidering local host-nation supply of blood products. sonnel with maximal capability. Limitations of scaled teams
must be clearly articulated to the Operational Command to
accurately communicate inherent risk.
Blood Warming
Conventional warming techniques for blood transfusion such Ruck
as the Belmont Rapid Infuser (Belmont Medical Technolo-
®
gies, https://www.belmontmedtech.com/) or plasma-thawing The Ruck model is the most mobile pack out because supplies
devices draw substantial power and may be unavailable in the and equipment are limited to what can be carried on each team
austere setting. Battery-operated, in-line products are easily member’s back. It is well understood that this is not the ideal
packed; however, flow rates are inversely proportional to infu- environment for surgical care; however, mission requirements
sion temperature and may be inadequate for the patient with occasionally dictate this capability. When it comes to surgical
trauma who is in severe hemorrhagic shock. Plasma-thawing intervention, or no intervention and likely casualty death, this
devices may be available in some equipment sets but may not substandard option becomes a mission requirement. Because

Austere Resuscitative and Surgical Care Guidelines | 33