Whole Blood for Civilian Urban Trauma Resuscitation: Historical, Present, and Future Considerations

Abstract

Whole blood (WB) has been used for more than a century for far-forward combat resuscitation. Following the Iraq/Afghanistan combat, maritime, and austere environment use of WB for the resuscitation of severely hemorrhaging patients, there has been an increasing use of WB for the civilian urban resuscitation environment population. The impetus for this was not just improved outcomes in far-forward hospitals, which had different populations and different needs than the civilian urban population, but also an application of the lessons suggested by recent 1:1:1 plasma:platelets:packed red cells fixed-ratio studies for patients with massive transfusion needs. Mechanistic, logistic, and standardization concerns have been addressed and are evolving as the WB project advances. A small number of studies have been published on WB in the civilian urban trauma population. In addition, European experience with viscoelastic testing and resuscitation with fibrinogen and prothrombin complex concentrate has provided another viewpoint regarding the choice of resuscitation strategies for severely bleeding trauma patients in urban civilian environments. There are randomized controlled trials in process, which are testing the hypothesis that WB may be beneficial for the civilian urban population. Whether WB will improve mortality significantly is now a matter of intense study, and this commentary reviews the history, mechanistic foundations, and logistical aspects for the use of WB in the civilian trauma population.

Advances in the Management of Coagulopathy in Trauma: The Role of Viscoelastic Hemostatic Assays across All Phases of Trauma Care

“…[42][43][44] Recently, there has been a return to stored low-titer O whole blood, which has been embraced in the United States but remains controversial in Europe, where resuscitation has historically been guided by VHA results and early empiric use of fibrinogen concentrate. 45,46 The superiority of one resuscitation strategy over another has yet to be established and is the topic of current study by multiple investigators. Ultimately, one must be cognizant of the development of hypothermia, acidosis, and coagulopathy, and act swiftly to avoid progression to the so-called "bloody vicious cycle" or lethal triad.…”

Perspectives on competencies for care in austere settings

“…Tactical Combat Casualty Care guidelines 9 ; the JTS CPGs on prehospital blood transfusion, 10 whole blood transfusion, 11 and damage-control resuscitation 11 ; and military and civilian reviews serve as useful references. [12][13][14][15][16] In advance of any missions, an inventory of vascular and intraosseous access supplies, blood collection supplies, hemostatic adjuncts, and available donors with known blood types/ antibody titers/communicable disease status must be performed. Patients with a traumatic mechanism who should be considered for blood product resuscitation include those with one or more traumatic limb amputations, penetrating torso trauma, or evidence of end-organ hypoperfusion.…”

The Complexity of Trauma-Induced Coagulopathy

“…Early nonrandomized trial data supports favorable results, as presented by Black et al, 11 but this empiric transfusion strategy remains as controversial as the use of TXA in trauma, with different institutions having polarizing opinions of its perceived benefit. This aspect is discussed by Walsh et al 12 We believe that the articles presented in this issue of Seminars of Thrombosis and Hemostasis will provide updated information on the complex topic of TIC and will be of much interest to clinicians and scientists in this rapidly growing field.…”