Page 18 - JSOM Summer 2022

his bleeding site. After ensuring that the second tourniquet is care would likely be deferred until their arrival on the LHA.
controlling the bleeding and has extinguished the distal pulse, Examples of deferred interventions might include enteral fluid
the proximal tourniquet may be loosened and left in place. resuscitation, rapid sequence intubation with end-tidal CO2
This casualty is assessed to likely have an injury to the super- monitoring, and suturing IV catheters into place. 27
ficial femoral artery. The bleeding is well-controlled with the Casualty 3
tourniquet repositioned.
This casualty has both a suspected pelvic fracture with non-
There is no other external bleeding, the femur seems stable compressible torso hemorrhage (NCTH) and a fractured
without evidence of fracture, and this appears to be an isolated femur. She is in hemorrhagic shock and has previously re-
injury with no indication of additional trauma. He has previ- ceived 2g of IV TXA and had an improvised pelvic binder ap-
ously had intravascular access established and received 2g of plied. She needs resuscitation with whole blood, preferably
20
TXA. He needs pain control, best accomplished with ketamine CS-LTOWB or fresh LTOWB as soon as possible, ketamine
(20–30mg IV or 50-100mg intranasally or intramuscularly) (not opioid) analgesia, splinting of her femur fracture with a
since his rapid, weak radial pulse indicates that he is likely hy- check of the distal pulse before and after splinting, and emer-
potensive. He will also need oral moxifloxacin. Resuscitation gent evacuation.
24
with blood, ideally whole blood, should be started as soon
as the blood becomes available; crystalloid should absolutely The TCCC-preferred fluid for resuscitation of casualties in
25,28,29
be avoided. The end point for resuscitation in this casualty hemorrhagic shock is whole blood. CS-LTOWB is an
should be a systolic blood pressure of 100mmHg. The casu- FDA-compliant whole blood product that should be used if
25
alty should be monitored and reassessed during resuscitation available, but the nearest source of cold-stored LTOWB is
to ensure that the bleeding has not resumed at his wound site the main CENTCOM blood bank at the Air Force Base in Al
due to the increased blood pressure and that there are no ad- Udeid, Qatar. There are frozen red blood cells and plasma on
ditional injuries. 26 the LHA, but those components, in the absence of platelets,
would not be as beneficial to the casualty as fresh Group O
Casualty 2 whole blood. 25,28,30–32
This severely burned patient is assessed to have second- and Since there are neither stored blood products nor a WBB ca-
third-degree burns covering 50% of his TBSA. The burns are pability on the casualty ship, the fastest way to obtain whole
located over most of the posterior surface of his body, without blood for transfusion to Casualty 3 is to activate one of the
any circumferential burns noted. He will require fluid resusci- two WBB options on the LHA. The crew of the LHA is one
tation and pain medication. Intravenous (IV) access should be option for donors from whom fresh units of universal donor
initiated and lactated Ringer’s solution (LR) should be infused Group O whole blood could be drawn. As described by Miller
using the USAISR Rule of Ten (initial infusion rate for adults et al, blood thus obtained would be screened for transfusion-
weighing between 40–80 kg = % TBSA burned × 10mL/hr). transmitted diseases at the time of collection and the Group
The casualty is estimated to weigh 70 kg and the initial infu- O type is confirmed by a laboratory technician from the Fleet
sion rate should therefore be 500mL/hr of LR. Since he is not Surgical Team. This Group O blood will not have anti-A and
in shock, OTFC is the fastest analgesic option for this casualty Anti-B antibody titers quantified but would avoid the risk of a
without hemodynamic or pulmonary compromise, but ket- major and possibly fatal major ABO mismatch. 33
amine is an acceptable and available alternative.
Another possibility for obtaining fresh whole blood in this
He should not have any cold compresses applied, but rather
should have clean, dry, warmed, lint-free blankets placed over scenario would be to obtain fresh LTOWB from the Marine
him to prevent hypothermia. There is no need to apply antibi- Corps personnel on board the LHA, since the Marine Corps is
34,35
otic creams or ointments at this stage of care. presently fielding that capability. If both options are avail-
able, the LTOWB from the USMC walking blood bank would
Although his burns are not observed to be circumferential, he be preferred over the untitered Type O blood from the LHA’s
should have careful monitoring of his respiratory status and walking blood bank. 25,28
the distal extremity pulses to ensure that there is no compro- If the WBB capability is properly trained and routinely exer-
mise of breathing or circulation due to the burns.
cised, whole blood could be drawn from the Group O donors
The following comments on Casualty 2 were provided by on the LHA and be ready to transport to the casualty ship in
COL Jennifer Gurney, a Surgeon at the US Army Institute of approximately 30 minutes. If whole blood collection begins
33
Surgical Research Burn Center: as soon as notice of the destroyer’s missile strike is received, it
should be ready to transport before the first evacuation heli-
“Oral or enteral resuscitation with oral rehydration flu- copter is cleared to depart the LHA.
ids or the WHO formula, as per the JTS Burn CPG,
can be started as tolerated and may reduce burn edema/ The approximate 90-minute delay to whole blood adminis-
total body edema. This size burn almost always requires tration that this approach entails is less than ideal but rep-
intubation with standard resuscitation algorithms. Re- resents the fastest time achievable given current Navy blood
suscitation adequacy is assessed with urine output, so as logistics at sea. Once available, whole blood should be infused
part of the initial treatments, a urinary catheter should in both Casualty 3 and Casualty 1 immediately and adminis-
be placed. At 50% TBSA burn, as soon as he gets his tered in accordance with TCCC Guidelines with a target SBP
first liter of fluid (or before), he will absolutely require of 100mmHg. 25
intubation” (personal communication – COL Jennifer This delay to whole blood resuscitation speaks to the need for
Gurney, 7 Nov 2021).
the establishment of walking blood banks on all Naval com-
Since both Casualty 2 and Casualty 5 are in a prehospital batant vessels. Whole blood is critically important to improv-
environment aboard the casualty ship, some aspects of burn ing this casualty’s chance for survival 30–32 and it needs to be

16 | JSOM Volume 22, Edition 2 / Summer 2022