Page 13 - JSOM Winter 2021

Joint Trauma System Clinical Practice Guideline (JTS CPG)

Prehospital Blood Transfusion
30 October 2020

MSG Jared Voller, MC, USA; CAPT Joshua M. Tobin, MC, USNR; COL Andrew P. Cap, MC, USA;
COL Cord W Cunningham, MC, USAR; HMC Michael Denoyer, MC, USN; CAPT Brendon Drew, MC, USN;
COL Jay Johannigman, MC, USAR; Elizabeth Mann-Salinas, PhD, COL(Ret), USA;
CAPT Benjamin D Walrath, MC, USN; COL Jennifer Gurney, MC, USA; Col Stacy A Shackelford, USAF, MC*

PURPOSE
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This Clinical Practice Guideline (CPG) provides a brief sum- O Fresh Whole Blood program. The main military literature
mary of the scientific literature for prehospital blood use, with covering this topic is summarized in Table 2 below.
an emphasis on the en route care environment. Updates in- Prehospital blood transfusions during an eight-month period
clude the importance of calcium administration to counteract in one system were reviewed and found to be logistically com-
the deleterious effects of hypocalcemia, minimal to no use of plex but practically possible with repetitive training. In an-
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crystalloid, and stresses the importance of involved and edu- other investigation, 15 patients safely received a total of 19
cated en route care medical directors alongside at a competent units of blood products according to pre-established guidelines
prehospital and en route care providers (see Table 1). With for blood product transfusion in U.S. Army Medical Evacua-
the paradigm shift to use FDA-approved cold stored low ti- tion (MEDEVAC) units in Afghanistan. Inclusion criteria for
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ter group O whole blood (CS-LTOWB) along with the opera- initiation of prehospital blood transfusion were: traumatic in-
tional need for continued use of walking blood banks (WBB) jury with systolic blood pressure (SBP) <90mmHg or heart rate
and point of injury (POI) transfusion, there must be focused, (HR) >120 bpm or oxygen saturation (SaO ) <90%. Following
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deliberate training incorporating the different whole blood the fifth transfused unit, oxygen saturation was excluded as a
options. Appropriate supervision of autologous blood transfu- transfusion trigger and multiple amputations (with at least one
sion training is important for execution of this task in support proximal amputation) were included as transfusion triggers.
of deployed combat operations as well as other operations in There were no adverse reactions and no instances of blood
which traumatic injuries will occur. Command emphasis on product temperature outside of the accepted range.
the importance of this effort as well as appropriate logistical
support are essential elements of a prehospital blood program Advanced clinical care during patient transport has demon-
as part of a prehospital/en route combat casualty care system. strated improved outcomes. 15-17 A growing body of evidence
suggests that early blood transfusion, both at point of in-
Keywords: prehospital; blood tranfusions; blood precautions; jury and en route to a surgical capability improves survival
JTS CPG in severely injured patients with acute blood loss. Rapid ini-
tiation of blood transfusion among wounded personnel in
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Afghanistan was evaluated among 502 patients. Patients
who had been transported via MEDEVAC; who had suffered
INTRODUCTION
a traumatic amputation at/above the knee/elbow; had SBP
Early administration of blood products to the trauma patient in <90mmHg or HR >120 bpm; and who had received blood
extremis is the standard in combat casualty care and becoming products during transportation, or, shortly after arrival in the
more common as part of a strategy of civilian prehospital crit- hospital, were compared to those who did not receive blood.
ical care. Although there is some dissent regarding the level Those who received blood were significantly less likely to die
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of evidence for and benefits of prehospital blood transfusion at 24 hours (adjusted hazard ratio for mortality 0.26 [95% CI
in the civilian literature, much of the data informing that dis- 0.08-0.84, p = 0.02]) as well as at 30 days (adjusted hazard
cussion precedes the use of whole blood and involves a patient ratio for mortality 0.39 [95% CI 0.16-0.92, p = 0.03]). This
population dissimilar from the military. Civilian Emergency study underscores the importance of early transfusion. The en
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Medical Services systems internationally 10,11 and in Texas, route care providers must continue (or in some cases start)
North Carolina, and several other states have initiated whole transfusion as soon as the casualty is in the aircraft. Blood
blood transfusions in the prehospital environment. At least one products that have started transfusion at POI can be continued
civilian tactical law enforcement team has initiated a Low-Titer during MEDEVAC.
*Correspondence to stacy.a.shackelford.mil@mail.mil

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