Page 104 - JSOM Fall 2025

Tf = (250 * 6) + (5000 * 35) / (250 + 5000) minority who argued against prehospital defibrillation. The
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rhetorically persuasive but analytically weak arguments against
Tf = 176,500 / 5250 = 33.6 the prehospital administration of LTOWB do not stand up to
the scientific evidence arguing against them. Concerns of com-
Thus, if we give a trauma patient with an approximate volume plications that range from an incidence of 0.00017%–0.005%,
of 5L of blood and a core temperature of 35°C a 250mL bolus when compared to the 50% mortality associated with hemor-
of whole blood at 6°C, the net change is 1.4°. This does not rhagic shock, demonstrate the fallibility of these arguments. 16–18
change if we assume a 2L volume loss and use a 3L starting
volume. While this is not negligible, other methods including The prehospital administration of LTOWB has emerged as a
heating the ambulance, and warm blankets may help to miti- highly effective intervention with growing evidence to support
gate some of this change. While it is clear that hypothermia is its benefits in saving lives compared to component therapy
deleterious in trauma, a small dose of cold blood can be safely or crystalloid fluids. Despite robust data from military and
administered provided other modalities of rewarming are in civilian settings demonstrating its safety, associated efficacy,
place. To that end, the argument that LTOWB must be warmed and feasibility, critics argue against its adoption in prehospi-
to be safely administered does not stand up to scientific rigor tal environments. Many of these arguments—such as concerns
and is likely to have limited clinical significance. over inadequate rewarming, transfusion reactions, or risks to
childbearing women—are very likely to have minimal impact
There is a Significant Risk for and a clinically negligible risk. It is imperative for the field of
Transfusion Reactions prehospital medicine to acknowledge the baselessness of these
arguments and instead focus on advancing the dissemination
Acute transfusion reactions are one of the more feared com- of and providing equitable access to LTOWB as a lifesaving
plications of blood transfusions, particularly in emergency prehospital intervention.
settings. These reactions run the gamut from minor reactions
to life-threatening ones and can be difficult to predict. Severe Disclosures
and life-threatening reactions are thankfully quite rare, with The author has nothing to disclose.
fatal autoimmune hemolytic reactions occurring in 0.0004%–
0.00017% of transfusions, transfusion-induced lung injury in Funding
approximately 0.04%–0.16% of transfusions, and anaphy- No funding was received for this work.
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laxis in approximately 0.005%–0.00213%. Kemp Bohan et
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al. looked at the incidence of all types of blood transfusion References
reactions in the prehospital setting of LTOWB administration 1. Torres CM, Kent A, Scantling D, Joseph B, Haut ER, Sakran JV.
and found a similarly low incidence. In comparison, the Association of whole blood with survival among patients present-
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overall mortality from hemorrhagic shock rests around 50%. ing with severe hemorrhage in US and Canadian adult civilian
Given the improvements in survival for prehospital LTOWB, trauma centers. JAMA Surg. 2023;158(5):532–540. doi:10.1001/
these risks are negligible in comparison. 16 jamasurg.2022.6978
2. Hazelton JP, Ssentongo AE, Oh JS, et al. Use of cold-stored whole
blood is associated with improved mortality in hemostatic resus-
Giving LTOWB to Women of Childbearing Age citation of major bleeding: a multicenter study. Ann Surg. 2022;
Puts Future Pregnancy at Risk 276(4):579–588. doi:10.1097/SLA.0000000000005603
3. Brill JB, Tang B, Hatton G, et al. Impact of incorporating whole
The argument that the risk of alloimmunization and subse- blood into hemorrhagic shock resuscitation: analysis of 1,377
quent hemolytic disease of the newborn is a significant risk fac- consecutive trauma patients receiving emergency-release uncross-
tor for the prehospital administration of LTOWB is frequently matched blood products. J Am Coll Surg. 2022;234(4):408–418.
doi:10.1097/XCS.0000000000000086
cited by critics of this practice. Like that of transfusion reac- 4. Morgan KM, Abou Khalil E, Feeney EV, et al. The efficacy of
tion, the risk is relatively low and preventable. Current data low-titer group O whole blood compared with component ther-
suggest that the risk of alloimmunization and hemolytic disease apy in civilian trauma patients: a meta-analysis. Crit Care Med.
of the newborn is around 0.1%, and death from hemolytic 2024;52(7):e390–e404. doi:10.1097/CCM.0000000000006244
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disease of the newborn is around 0.00039%. Similarly, the 5. Levy MJ, Garfinkel EM, May R, et al. Implementation of a pre-
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likelihood of a successful pregnancy and delivery of a healthy hospital whole blood program: lessons learned. J Am Coll Emerg
Physicians Open. 2024;5(2):e13142. doi:10.1002/emp2.13142
child to a mother who succumbs to hemorrhagic shock is 0%. 6. Turnbull C, Clegg L, Santhakumar A, Micalos PS. Blood product
Furthermore, in a national survey on this topic, 83% of woman administration in the prehospital setting: a scoping review. Pre-
were willing to get a field transfusion even if there was any risk hosp Emerg Care. 2025;29(5):645–658. doi:10.1080/10903127
to the fetus. This argument is grasping at an infinitesimally .2024.2386007
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small straw and will likely have no clinical significance. 7. Ferguson LB, Bullock W, Rayas EG, et al. Paramedic triggers for
transfusion of prehospital whole blood. Am J Emerg Med. 2024;
78:237–240. doi:10.1016/j.ajem.2024.01.020
Wherein Lies the Truth? 8. Sperry JL, Cotton BA, Luther JF, et al. Whole blood resuscitation
and association with survival in injured patients with an elevated
Scientific data are becoming increasingly proving that prehos- probability of mortality. J Am Coll Surg. 2023;237(2):206–219.
pital administration of blood is not only feasible but also safe doi:10.1097/XCS.0000000000000708
and saves lives. It will likely be one of the most groundbreak- 9. Guyette FX, Zenati M, Triulzi DJ, et al. Prehospital low titer group
ing advances and interventions in emergency medical services. O whole blood is feasible and safe: results of a prospective ran-
Therefore, it stands to reason that the critics of this intervention domized pilot trial. J Trauma Acute Care Surg. 2022;92(5):839–
847. doi:10.1097/TA.0000000000003551
need to be more transparent about the valid reasons for their 10. Orr LC, Peterson AL, Savell TC, et al. Whole blood program:
reluctance to endorse it. Despite mounting evidence, these critics implementation in a rural trauma center. J Trauma Nurs. 2024;31
continue to stand their ground, much like the small, now silent (5):258–265. doi:10.1097/JTN.0000000000000810

102 | JSOM Volume 25, Edition 3 / Fall 2025