Page 97 - JSOM Winter 2021

carrying the litter. At 2330, Patient A arrived at the second CCP wounds to the right upper thigh; a focused assessment with so-
and was reassessed. Vital signs revealed a decreased GCS score nography for trauma (FAST) was positive for abdominal fluid.
of 12, as the patient began sounding confused and eye open- He immediately underwent exploratory laparotomy where he
ing was to speech only, radial pulses were weak and oxygen was found to have injuries to the spleen (grade 5), colon, and
saturation was 89% on ambient air. Given the hypoxemia and left hemidiaphragm necessitating splenectomy, partial colonic
known thoracic wound, a left needle thoracostomy was per- resection, washout of the left thorax, diaphragmatic repair,
formed and hemorrhage control reassessed, which revealed a and temporary abdominal closure. He received 6 units red
slow oozing at the superior right thigh wound. The team leader blood cells (RBCs) and 4 units fresh frozen plasma (FFP). Af-
called for medical evacuation (MEDEVAC) while humeral and ter initial damage control surgery, he remained intubated and
sternal intraosseous (IO) lines and an 18-gauge intravascular sedated and underwent an uneventful 1.5-hour transfer flight
line were placed. The team leader initially informed the medics to the role 3 hospital.
that there were 8 minutes until exfiltration, therefore vascular
access was secured and the patient was packaged for transport. On role 3 arrival, his blood pressure had improved to 135/71
with heart rate of 95 bpm. He was taken to the operating
After the patient was packaged for evacuation, the team leader room where he underwent re-exploration of the abdomen,
discovered that the joint operations center had not received the washout of the left chest, colon anastomosis, diaphragm re-
nine-line MEDEVAC request. This meant there was at least 20 pair, abdominal closure as well as right groin exploration and
more minutes until exfiltration. At this point, patient A had a removal of X-stat sponges. He received an additional 1 unit
GCS of 11 and intermittent spontaneous respirations despite pRBCs, 2 units fresh frozen plasma (FFP), and 1 unit apheresis
repeat bilateral needle decompression and was being supported platelets. He required ongoing wound and respiratory care,
with intermittent assisted ventilations. Radial pulses contin- drainage of pleural and left upper quadrant fluid collections,
ued to be weak and thready. Due to the patient’s deterioration, and gradually improved. He was discharged from the role 3
which was assessed to be most likely due to hemorrhage, the after 18 days.
decision was made to initiate FWB transfusion.
Discussion
Transfusion Procedure
At approximately 0010, one medic was assigned to confirm Hemorrhage is the leading cause of mortality from potentially
patient A’s blood type and recruit suitable donors while an- survivable injuries on the battlefield, and most of these inju-
other medic administered tranexamic acid (TXA) via humeral ries are truncal (67.3%) followed by junctional (19.2%) and
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IO. Once a suitable donor was identified, the blood types of peripheral extremity (13.5%). Even with advances in junc-
both donor and recipient were confirmed using their respec- tional hemorrhage control techniques, truncal hemorrhage
tive blood identification cards. Due to tactical constraints, in- control cannot be accomplished on the battlefield. Improving
cluding restricted illumination and ongoing enemy presence, survivability on the battlefield requires managing the critically
an Eldon Card (Eldon Biological A/S, https://www.eldoncard wounded using alternative techniques until they can reach a
.com/) test was not performed. However, it should be empha- surgical capability.
sized that premission donor screening and issuance of blood
donor cards to both US military and Afghan partner forces, United States military data support that prehospital blood
were enforced and the donor procedure rehearsed. The stan- product transfusion within about 30 minutes of injury im-
11
dard procedure was to use a type-specific donor and confirm proves survival from combat trauma. This capability was
blood type of both donor and recipient using the issued blood initially implemented on MEDEVAC platforms in 2012, and
donor cards. The medic responsible to draw blood utilized a then expanded to Special Operations medics for use at the
Fenwal Single Collection Blood-Pack Unit (McKesson, https:// point of injury beginning in 2014. 3,22
mms.mckesson.com/product/581929/Fenwal-4R3611) for the
donor, as described in the Advanced Tactical Paramedic Proto- The Ranger Regiment first implemented the capability for
2
cols Handbook. At 0016, FWB transfusion to patient A was WBB procedures and FWB transfusion. However, as the capa-
3
flowing via sternal IO. Eight minutes later, half of the unit had bility to carry cold-stored, universal donor low-titer group O
been administered and MEDEVAC assets were on the ground. whole blood (LTOWB) was successfully advanced, the imple-
After administration of the half unit, vital signs had improved, mentation of WBB during real-world combat operations be-
respirations were back to 10–12 per minute with an improved came a backup plan with questionable feasibility that has only
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pulse of 90 beats per minute (bpm). The team loaded patient A rarely been executed. However, a WBB FWB approach offers
into the helicopter, conducted hasty handover, and continued some advantages over cold-stored blood as it requires fewer
with the mission. items and less weight for the medic to carry and avoids the
logistical challenges and extensive blood product wastage in-
Follow-on Care herent to the use of cold-stored products (Figure 1). Addition-
The patient underwent a 12-minute MEDEVAC flight from ally, FWB is associated with a survival advantage compared to
point of injury to role 2 with attached forward surgical team blood component therapy. 8–10
(FST). During the flight, he was hypotensive with blood pres-
sure estimated to be 60mmHg by palpation with a heart rate Currently there is a disparity between US military Special Oper-
of 90 bpm and an oxygen saturation of 72% on ambient air. ations and conventional forces for prehospital transfusion ca-
The blood transfusion was completed, and he underwent an pability. Conventional units seeking to implement prehospital
additional needle decompression prior to arriving at the FST transfusion are faced with a limited supply of LTOWB as well
location. On FST arrival, his blood pressure was 124/80 and as a formidable cost to purchase ruck-portable blood storage
heart rate 115 bpm. He was noted to have penetrating wounds solutions and hand-held blood warmers for all medics. Due
of the left upper quadrant of the abdomen, left flank and two to such barriers, many units are investigating the feasibility of

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