Page 15 - JSOM Winter 2021

NOTE: Conventional goal is systolic blood pressure >90mmhg. Rapid transfusion of blood can cause shearing of RBCs and
Recent concept indicates a higher goal of 90–110mmHg due to should be avoided if possible. When possible, low titer group
shift towards blood-based resuscitation and concern for pro- O whole blood (LTOWB) should be administered as the blood
longed hypoperfusion especially for patients with long trans- product of choice. LTOWB has been screened for Anti-A and
port times. Anti-B antibodies. The titer of these antibodies is low enough
to represent minimal risk of clinical consequences, and may be
CRITERIA FOR TRANSFUSION considered a universal donor. LTOWB will be exclusively drawn
from sites approved by the Armed Services Blood Program
Prehospital blood transfusion is predicated upon clearly de-
fined criteria for the use of this valuable resource. Several (ASBP), distributed in theater via the ASBP blood distribution
high performing military and civilian prehospital medical system and fully tested in accordance with FDA guidelines.
teams use prehospital blood transfusion according to proto- Blood products should be transfused in a plasma:platelet:RBC
colized guidelines. The U.S. Army Ranger Regiment was an ratio of 1:1:1. If platelets are not available, then plasma:RBC
early adopter of prehospital blood transfusion and uses the should be transfused in a 1:1 ratio. If that is not possible, then
following criteria for transfusion: signs and symptoms of reconstituted dried plasma, liquid plasma or thawed plasma
hemorrhagic shock; OR 1+ amputation; blunt/penetrating alone or RBCs alone should be transfused.
trauma (junctional/abdominal/thoracic); OR pelvic fracture;
OR SBP <100; OR lactate >5; pulse >100. In Australia, the If available, type O negative RBCs should be used preferentially
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Greater Sydney Area Helicopter Emergency Medical Services for females of child-bearing potential. If it is necessary to admin-
(GSA-HEMS) is an intensivist-based prehospital critical care ister O positive blood to a woman of childbearing years with
service that has extensive experience in prehospital blood O negative blood, then consider anti-D immunoglobin therapy
transfusion. In the prehospital environment, they transfuse therapy to decrease the risk to subsequent pregnancies. Please
blood if there is “persistent hemorrhagic shock despite hem- note though that resuscitation and prevention of exsanguina-
orrhage control measures after crystalloid infusion.” During tion takes precedence of potential future pregnancy complica-
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interhospital transport GSA-HEMS transfuses blood if there tions. Pediatric blood transfusion should be based on clinical
is “persistent hemorrhagic shock where there is limited or no signs of shock rather than predefined vital signs, since vital signs
access to cross-matched blood and [an] ongoing requirement can vary considerably between age groups in pediatric patients.
for transfusion.” The Australian Queensland Ambulance Ser- Blood plasma contains important clotting factors and can be
vice Trauma Response Team administers blood products in the transfused rapidly. Thawed plasma has a shelf life of 5 days
prehospital environment and a retrospective review of cases and may not be available for prehospital missions. “Never
was published in 2014 demonstrating benefit in appropriate frozen” liquid plasma has a shelf life of 26 days in CPD and
clinical situations In 2014, proposed criteria for prehospi- 40 days in CPDA-1 storage solution and may be more read-
.22
tal blood products in combat casualties were refined based on ily available. Check with the issuing facility for availability of
data from Afghanistan and updated in 2020 using a larger thawed or liquid (i.e. never frozen) plasma. All blood products
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data set from the entire DoD Trauma Registry (DoDTR). A must be transfused immediately after removal from the storage
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case series reviewing the benefits of early whole blood admin- container. If transfusion is delayed, then blood products that
istration in combat casualties was published in 2016. 25 have been removed from storage and exceeded proper tem-
perature will be returned to the issuing facility per local policy.
Development of transfusion criteria is an important consider- Ensure that all blood products issues have a Safe-T-VUE (NSN
ation in establishment of a prehospital transfusion program. 6515-08-T00-3056) attached and activated for temperature
In the civilian trauma center experience, 596 trauma patients monitoring (see Appendix E).
were evaluated using an assessment of blood consumption
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(ABC) score. Patients received one point for any of the fol-
lowing: penetrating mechanism; positive focused assessment so- QUALITY CONTROL
nography for trauma (FAST); systolic blood pressure less than Proper storage, transport and administration of blood and
90mmHg; heart rate greater than or equal to 120 beats per min- blood products is addressed the following Joint Trauma System
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ute. An ABC score of two or greater predicted the need for mas- CPGs: Damage Control Resuscitation, Frozen and Deglycer-
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sive blood transfusion with 75% sensitivity and 86% specificity. olized Red Blood Cells, and Whole Blood Transfusions.
This investigation demonstrated the utility of a quick, non- Ensure that the blood product container (NSN 6530-01-
laboratory based tool to predict the need for blood transfusion.
505-530I; OCP/5306; Desert) is properly charged and main-
Careful attention to transfusion triggers can limit wastage of tained prior to loading blood products. Ensure that all blood
this important resource in a potentially resource constrained products have a Safe-T-VUE attached and activated for tem-
environment. Furthermore, it is important to note that blood perature monitoring. Ensure that thawed plasma is at a re-
product usage can be optimized when hemorrhage control is frigerated temperature (1–6 degrees C) prior to placement
undertaken simultaneously. Ensure that hemorrhage con- of Safe-T-VUE. Appropriately document issuance and use of
5,7
trol efforts are properly employed in accordance with Tacti- blood products per local protocol, including documentation in
cal Combat Casualty Care Guidelines. When administering Theater Medical Data Store (TMDS) inventory.
blood, be certain to alert the receiving facility that the patient
is requiring blood transfusion, noting any potential need for Blood products carried outside of a medical treatment facil-
massive transfusion. ity (MTF) and/or laboratory will be contained in an approved
storage container for a maximum of 48 hours. Once loaded
and sealed, a container will remain closed and intact until used
PROCEDURE
for patient care or returned to the issuing facility. Units will
Certain special considerations for blood transfusion have been inspect blood product containers and document appropriate
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enacted in other Department of Defense transfusion algorithms. quality metrics (e.g., intact, no leaking) every 24 hours.
Prehospital Blood Transfusion | 13