Low titer group O whole blood resuscitation: Military experience from the point of injury.

INTRODUCTION: In the far forward combat environment, the use of whole blood is recommended for the treatment of hemorrhagic shock after injury. In 2016, US military special operations teams began receiving low titer group O whole blood (LTOWB) for use at the point of injury (POI). This is a case series of the initial 15 patients who received LTOWB on the battlefield. METHODS: Patients were identified in the Department of Defense Trauma Registry, and charts were abstracted for age, sex, nationality, mechanism of injury, injuries and physiologic criteria that triggered the transfusion, treatments at the POI, blood products received at the POI and the damage-control procedures done by the first surgical team, next level of care, initial interventions by the second surgical team, Injury Severity Score, and 30-day survival. Descriptive statistics were used to characterize the clinical data when appropriate. RESULTS: Of the 15 casualties, the mean age was 28, 50% were US military, and 63% were gunshot wounds. Thirteen patients survived to discharge, one died of wounds after arrival at the initial resuscitative surgical care, and two died prehospital. The mean Injury Severity Score was 21.31 (SD, 18.93). Eleven (68%) of the causalities received additional blood products during evacuation/role 2 and/or role 3. Vital signs were available for 10 patients from the prehospital setting and 9 patients upon arrival at the first surgical capable facility. The mean systolic blood pressure was 80.5 prehospital and 117 mm Hg (p = 0.0002) at the first surgical facility. The mean heart rate was 105 beats per minute prehospital and 87.4 beats per minute (p = 0.075) at the first surgical facility. The mean hospital stay was 24 days. CONCLUSION: The use of cold-stored LTOWB at POI is feasible during combat operations. Further data are needed to validate and inform best practice for POI transfusion. LEVEL OF EVIDENCE: Therapeutic study, level V.

Management of Hypothermia in Tactical Combat Casualty Care: TCCC Guideline Proposed Change 20-01 (June 2020).

As an outcome of combat injury and hemorrhagic shock, trauma-induced hypothermia (TIH) and the associated coagulopathy and acidosis result in significantly increased risk for death. In an effort to manage TIH, the Hypothermia Prevention and Management Kit™ (HPMK) was implemented in 2006 for battlefield casualties. Recent feedback from operational forces indicates that limitations exist in the HPMK to maintain thermal balance in cold environments, due to the lack of insulation. Consequently, based on lessons learned, some US Special Operations Forces are now upgrading the HPMK after short-term use (60 minutes) by adding insulation around the casualty during training in cold environments. Furthermore, new research indicates that the current HPMK, although better than no hypothermia protection, was ranked last in objective and subjective measures in volunteers when compared with commercial and user-assembled external warming enclosure systems. On the basis of these observations and research findings, the Committee on Tactical Combat Casualty Care decided to review the hypothermia prevention and management guidelines in 2018 and to update them on the basis of these facts and that no update has occurred in 14 years. Recommendations are made for minimal costs, low cube and weight solutions to create an insulated HPMK, or when the HPMK is not readily available, to create an improvised hypothermia (insulated) enclosure system.

Implementation of a low titer group O whole blood program for a law enforcement tactical team.

The Texas Ranger Special Operations Group (SOG) performs high-risk warrant service and responds to callouts for evolving kinetic situations and special missions as required. These operations may occur many hours from a trauma center. Fresh whole blood (FWB) transfusions may offer a stopgap for those who are critically injured. To make FWB transfusions a viable option, several steps must be implemented. The following lays out how the Texas Ranger SOG will implement and conduct FWB transfusions using low titer group O whole blood. The techniques outlined may be useful for communities that may face critical blood shortage in disasters.

Management of Hemorrhage From Craniomaxillofacial Injuries and Penetrating Neck Injury in Tactical Combat Casualty Care: iTClamp Mechanical Wound Closure Device TCCC Guidelines Proposed Change 19-04 06 June 2019.

The 2012 study Death on the battlefield (2001-2011) by Eastridge et al.1 demonstrated that 7.5% of the prehospital deaths caused by potentially survivable injuries were due to external hemorrhage from the cervical region. The increasing use of Tactical Combat-Casualty Care (TCCC) and other medical interventions have dramatically reduced the overall rate of combat-related mortality in US forces; however, uncontrolled hemorrhage remains the number one cause of potentially survivable combat trauma. Additionally, the use of personal protective equipment and adaptations in the weapons used against US forces has caused changes in the wound distribution patterns seen in combat trauma. There has been a significant proportional increase in head and neck wounds, which may result in difficult to control hemorrhage. More than 50% of combat wounded personnel will receive a head or neck wound. The iTClamp (Innovative Trauma Care Inc., Edmonton, Alberta, Canada) is the first and only hemorrhage control device that uses the hydrostatic pressure of a hematoma to tamponade bleeding from an injured vessel within a wound. The iTClamp is US Food and Drug Administration (FDA) approved for use on multiple sites and works in all compressible areas, including on large and irregular lacerations. The iTClamp's unique design makes it ideal for controlling external hemorrhage in the head and neck region. The iTClamp has been demonstrated effective in over 245 field applications. The device is small and lightweight, easy to apply, can be used by any level of first responder with minimal training, and facilitates excellent skills retention. The iTClamp reapproximates wound edges with four pairs of opposing needles. This mechanism of action has demonstrated safe application for both the patient and the provider, causes minimal pain, and does not result in tissue necrosis, even if the device is left in place for extended periods. The Committee on TCCC recommends the use of the iTClamp as a primary treatment modality, along with a CoTCCC-recommended hemostatic dressing and direct manual pressure (DMP), for hemorrhage control in craniomaxillofacial injuries and penetrating neck injuries with external hemorrhage.

Conducting fresh whole blood transfusion training.

Fresh whole blood is the optimal resuscitation fluid for casualties in hemorrhagic shock according to the Committee on Tactical Combat Casualty Care and has demonstrated to improve outcomes in severely wounded patients. Like all medical interventions, fresh whole blood transfusions are not without risks, but similarly can be mitigated through increased training to develop provider knowledge and proficiency. To date, no literature has been published regarding the proper technique to conduct fresh whole blood transfusion training. This article provides a structured foundation to establish a standardized fresh whole blood transfusion training program to increase skill and preparedness for fresh whole blood protocol implementation. Using these techniques in a training environment, providers will be able to provide optimal resuscitation in hemorrhagic shock in austere environments.

Changes in donor antibody titer levels over time in a military group O low-titer whole blood program.

BACKGROUND: The ability to rapidly administer whole blood (WB) at the point of injury is an important intervention to save lives. This can be accomplished using low titer group O WB donors. Titers of immunoglobulin M anti-A and anti-B might change over time. This study describes titer testing in a large series of donors. STUDY DESIGN AND METHODS: Data were collected retrospectively from the Armed Services Blood Program and the Theater Medical Data Store. Soldiers assigned to the 75th Ranger Regiment were screened and titered upon completion of training or before deployment or during periodic unit readiness activities. A Ranger group O low-titer (ROLO) donor was defined as having titers of both anti-A and -B of less than 256 by immediate spin testing. RESULTS: Between May 2015 and January 2017, of a total of 2237 participating soldiers, 1892 (84.5%) soldiers underwent antibody titering once, while 266 (11.9%) were titered twice, 62 (2.8%) were titered three times, and 17 (0.8%) were titered at least four times. The mean age was 26.5 ± 6.5, and 2197 (98.2%) were male. A total of 69.5% of donors met ROLO donor criteria on the first test. The percentage of donors meeting universal-donor criteria increased to 83.5% on the second test, 91.1% on the third test, and 100% on the fourth and fifth tests. CONCLUSIONS: With successive titer testing, it appears that individuals display a tendency toward lower titers. This may indicate that titer testing may not be required after the second test if donors have been identified initially as low titer.

Advanced Resuscitative Care in Tactical Combat Casualty Care: TCCC Guidelines Change 18-01:14 October 2018.

TCCC has previously recommended interventions that can effectively prevent 4 of the top 5 causes of prehospital preventable death in combat casualties-extremity hemorrhage, junctional hemorrhage, airway obstruction, and tension pneumothorax- and deaths from these causes have been markedly reduced in US combat casualties. Noncompressible torso hemorrhage (NCTH) is the last remaining major cause of preventable death on the battlefield and often causes death within 30 minutes of wounding. Increased use of whole blood, including the capability for massive transfusion, if indicated, has the potential to increase survival in casualties with either thoracic and/or abdominopelvic hemorrhage. Additionally, Zone 1 Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) can provide temporary control of bleeding in the abdomen and pelvis and improve hemodynamics in casualties who may be approaching traumatic cardiac arrest as a result of hemorrhagic shock. Together, these two interventions are designated Advanced Resuscitative Care (ARC) and may enable casualties with severe NCTH to survive long enough to reach the care of a surgeon. Although Special Operations units are now using whole blood far-forward, this capability is not routinely present in other US combat units at this point in time. REBOA is not envisioned as care that could be accomplished by a unit medic working out of his or her aid bag. This intervention should be undertaken only by designated teams of advanced combat medical personnel with special training and equipment.

The Role I Resuscitation Team and Resuscitative Endovascular Balloon Occlusion of the Aorta.

The medical advancements made during the wars in Iraq and Afghanistan have resulted in an unprecedented survival rate, yet there is still a significant number of deaths that were potentially survivable. Additionally, the ability to deliver casualties to definitive surgical care within the "golden hour" is diminishing in many areas of conflict. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been implemented successfully in the hospital setting. REBOA may be a possible adjunct for the Role I and point-of-injury (POI) care to provide temporary control of noncompressible torso hemorrhage (NCTH) and junctional hemorrhage. Here the authors advocate for the development of the Role I Resuscitation Team (RT) and a training pathway to meet the challenge of the changing battlefield.

Volumetric control of whole blood collection in austere environments.

INTRODUCTION: Fresh whole blood transfusions are a powerful tool in prehospital care; however, the lack of equipment such as a scale in field situations frequently leads to collections being under- or overfilled, leading to complications for both patient and physician. This study describes two methods for simple, rapid control of collection bag volume: (1) a length of material to constrict the bag, and (2) folding/clamping the bag. METHOD: Whole blood collection bags were allowed to fill with saline via gravity. Paracord, zip-tie, beaded cable tie, or tourniquet was placed around the bag at circumferences of 6 to 8.75 inches. A hemostat was used to clamp folds of 1 to 1.5 inches. Several units were drawn during training exercises of the 75th Ranger Regiment with volume controlled by three methods: vision/touch estimation, constriction by paracord, and clamping with hemostat. RESULTS: Method validation in the Terumo 450-mL bag indicated that paracord, zip-tie, and beaded cable tie lengths of 6.5 inches or clamping 1.25 inches with a hemostat provided accurate filling. The volume variance was significantly lower when using the beaded cable tie. Saline filling time was approximately 2 minutes. With the Fenwal 450-mL bag, the beaded cable tie gave best results; even if incorrectly placed by one/two beads, the volume was still within limits. In training exercises, the use of the cord/clamp greatly reduced the variability; more bags were within limits. CONCLUSIONS: Both constricting and clamping allow for speed and consistency in blood collection. The use of common cord is appealing, but knot tying induces inevitable variability; a zip/cable tie is easier. Clamping was quicker but susceptible to high variance and bag rupturing. With proper methodological training, appropriate volumes can be obtained in any environment with minimal tools. LEVEL OF EVIDENCE: Therapeutic/care management study, level IV.

Leadership and a casualty response system for eliminating preventable death.

Combat casualties who die from their injuries do so primarily in the prehospital setting. Although most of these deaths result from injuries that are nonsurvivable, some are potentially survivable. Of injuries that are potentially survivable, most are from hemorrhage. Thus, military organizations should direct efforts toward prehospital care, particularly through early hemorrhage control and remote damage control resuscitation, to eliminate preventable death on the battlefield. A systems-based approach and priority of effort for institutionalizing such care was developed and maintained by medical personnel and command-directed by nonmedical combatant leaders within the 75th Ranger Regiment, U.S. Army Special Operations Command. The objective of this article is to describe the key components of this prehospital casualty response system, emphasize the importance of leadership, underscore the synergy achieved through collaboration between medical and nonmedical leaders, and provide an example to other organizations and communities striving to achieve success in trauma as measured through improved casualty survival.

A Case of Prehospital Traumatic Arrest in a US Special Operations Soldier: Care From Point of Injury to Full Recovery.

During an assault on an extremely remote target, a US Special Operations Soldier sustained multiple gunshot and fragmentation wounds to the thorax, resulting in a traumatic arrest and subsequent survival. His care, including care under fire, tactical field care, tactical evacuation care, and Role III, IV, and V care, is presented. The case is used to illustrate the complex dynamics of Special Operations care on the modern battlefield and the exceptional outcomes possible when evidence-based medicine is taken to the warfighter with effective, farforward, expeditionary medical-force projection.

Telemedicine to Reduce Medical Risk in Austere Medical Environments: The Virtual Critical Care Consultation (VC3) Service.

One of the core capabilities of prolonged field care is telemedicine. We developed the Virtual Critical Care Consult (VC3) Service to provide Special Operations Forces (SOF) medics with on-demand, virtual consultation with experienced critical care physicians to optimize management and improve outcomes of complicated, critically injured or ill patients. Intensive-care doctors staff VC3 continuously. SOF medics access this service via phone or e-mail. A single phone call reaches an intensivist immediately. An e-mail distribution list is used to share information such as casualty images, vital signs flowsheet data, and short video clips, and helps maintain situational awareness among the VC3 critical care providers and other key SOF medical leaders. This real-time support enables direct communication between the remote provider and the clinical subject matter expert, thus facilitating expert management from near the point of injury until definitive care can be administered. The VC3 pilot program has been extensively tested in field training exercises and validated in several real-world encounters. It is an immediately available capability that can reduce medical risk and is scalable to all Special Operations Command forces.

Tactical Damage Control Resuscitation.

Recently the Committee on Tactical Combat Casualty Care changed the guidelines on fluid use in hemorrhagic shock. The current strategy for treating hemorrhagic shock is based on early use of components: Packed Red Blood Cells (PRBCs), Fresh Frozen Plasma (FFP) and platelets in a 1:1:1 ratio. We suggest that lack of components to mimic whole blood functionality favors the use of Fresh Whole Blood in managing hemorrhagic shock on the battlefield. We present a safe and practical approach for its use at the point of injury in the combat environment called Tactical Damage Control Resuscitation. We describe pre-deployment preparation, assessment of hemorrhagic shock, and collection and transfusion of fresh whole blood at the point of injury. By approaching shock with goal-directed therapy, it is possible to extend the period of survivability in combat casualties.

Central retinal vein occlusion in an Army Ranger with glucose-6-phosphate dehydrogenase deficiency.

Glucose-6-phosphate dehydrogenase (G6PD) deficiency is the most prevalent human enzyme deficiency, affecting an estimated 400 million people worldwide. G6PD deficiency increases erythrocyte vulnerability to oxidative stress and may precipitate episodes of hemolysis when individuals are exposed to triggering agents. Although central retinal vein occlusion (CRVO) does occur in G6PD-deficient individuals, G6PD-deficient individuals exposed to oxidative stressors have not been previously reported to have an increase in CRVO incidence. This is a case of an Army Ranger who deployed to Afghanistan with unrecognized G6PD deficiency and was placed on primaquine following his return to the United States and subsequently developed CRVO. Primaquine is a well-recognized cause ofhemolysis in individuals with G6PD deficiency. Hemolytic anemia may contribute to thrombosis as a result of increased erythrocyte aggregation and erythrocyte-endothelium interaction. This case underscores the continued need for routine G6PD screening and avoidance of known triggers in G6PD-deficient individuals.

Central retinal vein occlusion in an Army ranger with glucose-6-phosphate dehydrogenase deficiency.

Glucose-6-phosphate dehydrogenase (G6PD) deficiency is the most prevalent human enzyme deficiency, affecting an estimated 400 million people worldwide. G6PD deficiency increases erythrocyte vulnerability to oxidative stress and may precipitate episodes of hemolysis when individuals are exposed to triggering agents. Although central retinal vein occlusion (CRVO) does occur in G6PD-deficient individuals, G6PD-deficient individuals exposed to oxidative stressors have not been previously reported to have an increase in CRVO incidence. This is a case of an Army Ranger who deployed to Afghanistan with unrecognized G6PD deficiency and was placed on primaquine following his return to the United States and subsequently developed CRVO. Primaquine is a well-recognized cause of hemolysis in individuals with G6PD deficiency. Hemolytic anemia may contribute to thrombosis as a result of increased erythrocyte aggregation and erythrocyte-endothelium interaction. This case underscores the continued need for routine G6PD screening and avoidance of known triggers in G6PD-deficient individuals.