Page 92 - JSOM Winter 2021

Prehospital Iliac Crest Intraosseous Whole Blood Infusion

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George Fulghum, DO *; Brian Gravano ; Andrew Foudriat ;
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Stephen Rush, MD ; Lorenzo Paladino, MD 5
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ABSTRACT
Low-titer cold-stored O-positive whole blood (LTCSO+WB) placement, peripheral pulses were absent, except for a tran-
resuscitation therapy is the cornerstone of military hemor- sient, faint radial pulse on the right, where an improvised tour-
rhagic shock resuscitation. During the past 19 years, improved niquet had been applied proximally. The patient was mildly
patient outcomes have shown the importance of this interven- confused with a Glasgow Coma Scale (GCS) score of 14.
tion in shock treatment. Iliac crest intraosseous (IO) placement He was tachycardic to 140 beats per minute (bpm) and was
is an alternative when peripheral sites such as the humeral breathing at 24 breaths per minute with an oxygen saturation
head and tibia are not available options. To date, no study has (SpO ) of 89%. His skin was cool and clammy.
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explored the administration of LTCSO+WB through an iliac
crest IO in the military prehospital setting. Contingency pro- The pararescueman determined the casualty was in shock
cedures for vascular access are necessary for casualties with based on the mechanism of injury, tachycardia, skin exam, and
severe trauma to all four extremities, and the iliac crest is a mild confusion. Thus, vascular access and blood transfusion
viable option. The literature supports situational advantages were indicated. Peripheral extremity or external jugular ve-
over other peripheral IO sites. nous access was contraindicated due to tourniquet placement
and penetrating neck trauma. Sternal IO was considered, but
Keywords: whole blood transfusion; vascular access; pararescue; the patient’s upper chest and neck were deemed to be compro-
trauma; intraosseous; iliac crest mised by trauma and the impaled foreign body in close prox-
imity to the sternal site. A 15-gauge 45-mm EZ-IO (Teleflex,
https://www.teleflex.com/) needle was drilled into the patient’s
left iliac crest. Placement and patency were confirmed with
Introduction
marrow aspiration and flushing. LTCSO+WB was transfused
We present a case of whole blood transfusion via iliac crest IO via pressure infuser to 300mmHg. During the remaining 12
in a 50-year-old patient who was injured by a vehicle borne minutes of flight, 350mL of blood was transfused. Other in-
improvised explosive device (VBIED) and subsequently devel- flight treatment included reassessment of hemorrhage control,
oped hemorrhagic shock. Peripheral access could not be estab- hypothermia prevention, and pain management, with TXA
lished due to injury and subsequent tourniquet application on and antibiotics given upon arrival to the surgical team.
all four limbs. Cervical and upper thoracic trauma precluded
sternal placement. LTCSO+WB was administered through an Upon arrival to the Role 2 forward staged operating theater,
iliac crest IO, which improved hemodynamic status. This is the the casualty’s heart rate improved to 115 bpm and blood pres-
first report of a whole blood transfusion through an iliac crest sure was 120/90mmHg. His GCS score was 15. Exposure for
IO for hemorrhagic shock in the military prehospital setting. complete assessment revealed multiple penetrating injuries to
the right neck, left chest, abdomen, and all four extremities.
He was subsequently placed under anesthesia and prepared
Case Presentation
for surgery.
A 50-year-old man on dismounted patrol was injured in a
VBIED blast. This resulted in widespread penetrating trauma During surgery, a right anterior neck exploration for a zone 2
to all four limbs with active bleeding, and impaled objects in injury was performed. Intraoperatively, no major cerebrovas-
his right neck, right abdomen, and right knee. Ground medics cular injury was identified. The common carotid and internal
applied tourniquets to all four extremities at the point of in- jugular vein were loosely controlled with vessel loops and the
jury and gave the casualty a fentanyl lozenge. vagus nerve was protected. Bleeding was controlled from a
lacerated sternocleidomastoid muscle and superficial venous
An Air Force Pararescue team traveling in two HH-60 “Pave- sources. A median sternotomy with right supraclavicular ex-
hawk” helicopters arrived on scene 47 minutes following the tension was required to expose and shunt a near complete
explosion to evacuate the casualty. The initial assessment transection of the first portion of the subclavian artery just dis-
demonstrated that bleeding was controlled. Due to tourniquet tal (< 1 cm) to the thyrocervical trunk and internal mammary
*Correspondence to George.H.Fulghum2.mil@mail.mil
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1 Dr George Fulghum is a general surgeon affiliated with the US Air Force. Brian Gravano and Andrew Foudriat are affiliated with US Air Force
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Pararescue. Dr Stephen Rush is affiliated with the 106th Medical Group of the US Air Force. Dr Lorenzo Paladino is affiliated with the 103rd
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Rescue Squadron of the US Air Force.
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