Page 21 - JSOM Summer 2022

CAT C – Routine (Mild to Moderate Injury) The guidance found for surface ships in the 2014 US Navy
None Shipboard Medical Procedures Manual states that:
Having the Emergency Medicine physician from the Shock/ “A ‘walking blood bank’ shall be utilized as a tertiary
Trauma Platoon embarked on the LHA transported to the ca- blood source when neither liquid blood products nor
sualty ship on the first evacuation helicopter would provide thawed and washed cells are available. The use of walk-
a valuable physician resource to assist in preparing the first ing donors and emergency blood collections, although
group of casualties for evacuation and in providing care for sometimes necessary, is not encouraged due to the lack
the casualties who remain on the casualty ship awaiting trans- of the capability to perform serological testing for infec-
port on subsequent flights. He or she could also perform ad- tious diseases.” 49
vanced interventions and transfuse blood as needed.
Casualty Receiving and Treatment Ships such as the LHA in
Casualty 5’s injuries are severe and long-term survival is un- this scenario have frozen red blood cells and frozen plasma,
likely given the extent of her burns. Her transport to the LHA but 1) those two components in the absence of platelets are
is less time-sensitive than the other casualties’ in that the op- not as effective as LTOWB, 25,28,29,30–32,50 and 2) it takes time to
portunity to save life or limb is lower in this individual with thaw frozen plasma and red blood cells unless those units have
extensive burns. Her surgical airway has already been per- been pre-thawed as part of medical contingency planning. The
formed and escharotomies can be performed on the casualty 2016 Joint Trauma System CPG on Frozen and Deglycerolized
ship under ketamine sedation if needed. Red Blood Cells notes that:
Also, after establishing an evacuation precedence order for the ‘Thawing and deglycerolization are time-consuming
casualties, it is likely that that initial priority may have to be processes. Thawing a frozen RBC unit takes about 35
revised based on the evolving clinical status of the casualties minutes in a plasma thawer and about 45 minutes in a
while awaiting transport to the LHA. For example, Casualty 42°C water bath. Deglycerolization of one unit in the
3 with the abdominopelvic NCTH and shock may not survive ACP215 takes about one hour. Real world use of this
for 90 minutes without a whole blood transfusion and surgical technology suggests that a single technician operating
control of her hemorrhage. If she does suffer a traumatic car- three ACP215’s can prepare three units of DRBCs ev-
diac arrest before leaving the casualty ship, CPR and emergent ery three hours. In periods of predictable operational
transport are not warranted, since recovery from a traumatic requirements, it may be advisable to pre-thaw and de-
cardiac arrest resulting from exsanguination in which there is glycerolize several units so as not to incur the delay of
a significant delay to definitive care is exceedingly unlikely. 48 preparation at the time they are needed.” 51

Additional considerations may also come into play such as the The recent Joint Consensus Statement from the Joint Trauma
intensity of medical care needed during transport. If the EM System, the Defense Committee on Trauma and the Armed
physician intubates one or more of these casualties, those ca- Services Blood Program states that:
sualties might require an additional medical attendant during “Component therapy, which includes red blood cells,
the transport to the LHA. This would result in only a single plasma, and platelets separated from the whole blood
casualty being able to be transported on that flight.
from which it was derived, has commonly been used to
Finally, the total time required to evacuate all of the casual- support all types of transfusion needs since World War
ties from the casualty ship could be reduced if the LHA and II. However, component therapy is technically more dif-
the casualty ship alter course and speed to close the distance ficult to deliver to massively bleeding casualties (partic-
between them, if that is determined to be a tactically sound ularly in austere environments), dilutes clotting factors,
course of action. The decreasing separation between the ships and has been shown to be associated with increased
would thus result in shorter evacuation flight times. mortality compared to FWB in retrospective studies of
military casualties…Frozen red blood cell stockpiles,
Discussion while attractive for contingency operations and plan-
Whole Blood for Shipboard Casualties in ning due to their extended shelf life, are inadequate
Hemorrhagic Shock to support resuscitation of acutely bleeding casualties.
The TCCC-preferred resuscitation fluid for casualties in hem- Thawing and deglycerolization of frozen red blood cells
orrhagic shock is FDA-compliant, cold-stored LTOWB. 25,28,30–32 cannot be done rapidly, and even when combined with
When this whole blood product is not available, the second plasma thawing, does not supply platelets, and results in
choice is fresh LTOWB from a prescreened, low-titer O donor suboptimal resuscitation.” 31
pool. 25,28 Miller and colleagues described the clinical impact of warm
At present, however, small combatant ships such as destroyers fresh whole blood in the mass casualty event that they treated
have neither cold-stored LTOWB on board nor a WBB capa- on the USS Bataan:
bility. Even if a WBB were in place, the WBB response might “Patient 3, obviously the most critically injured, benefited
be constrained by the need for crew personnel to be in place at the most from WFWB (Warm Fresh Whole Blood) resus-
their battle stations or to fight fires and flooding, thus reduc- citation. He was profoundly acidotic immediately follow-
ing the number of potential donors. If WBBs were to be estab- ing approximately 30 minutes of aortic cross-clamping
lished on smaller combatants, such as a destroyer, it would be and an emergent abdominal operation, during which
critical to plan for the right mix of sailors in the donor pool. he received only component therapy. Within an hour
Clerical or administrative sailors might be more suitable as after his initial operation, he returned to the operating
potential donors, since they would be less likely to be engaged room for hemorrhage, likely the result of coagulopathy
in combat or damage control duties. from the unbalanced resuscitation with pRBCs and FFP

TCCC Maritime Scenario: Shipboard Missile Strike | 19