components. Most services that carry blood
components are helicopter-based. There are a
few published studies, with varying outcomes.
A study of prehospital blood product transfusion in Afghanistan recently presented data that
demonstrated a 20-fold survival benefit when
blood is given within 34 minutes of injury,
recent data from the U.K. suggest prehospital
blood may reduce transfusion requirements.
Although combat data doesn’t always correlate
with civilian medicine, this data may
still present some benefit for EMS.
Trauma is the leading cause of
death for patients under 46 years
old, and uncontrolled hemorrhage
remains the number one cause of preventable death in trauma.
11 Even in
urban areas, the role of blood transfusions is relevant. The time is now for
EMS to embrace blood as the fluid of
choice in trauma resuscitation.
In 2011, an international group of physicians,
blood bankers and researchers formed the
Trauma Hemostasis and Oxygenation Research
(THOR) Network and held the first Remote
Damage Control Resuscitation (RCDR) Symposium in Norway.
This group advocated for the use of whole
blood with one of the co-founders, Geir
Strandenes, developing a low titer group O
whole blood (LTOWB) program for Norwe-
gian Naval Special Operation Commando.
This information was used by the U.S. Army’s
75th Ranger Regiment, in conjunction with
the U.S. Army Institute of Surgical Research
and Armed Services Blood Program (ASBP),
to develop the first LTOWB program that
screened donors before deployment for use
at the POI.
Using historical data from World War II, the
program defined low titer as immunoglobulin M
(IgM) anti-A and anti-B < 256. Volunteers
were tested for transmitted transfusion diseases
(TTDs) and titer tested prior to deployment.
Although the ROLO program was initially
designed to deliver fresh whole blood (FWB),
the chaotic nature of combat makes drawing a
unit of FWB difficult.
To decrease the amount of time it takes to
administer a unit of FWB, the ASBP began
shipping cold-stored LTOWB to Afghanistan
in March 2016, with the first unit being administered in later the same month. The cold-stored
LTOWB product is an FDA licensed product,
with an IgM anti-A and anti-B titer of < 150.
There are three options for using LTOWB.
The first option is to draw a unit of FWB from a
prescreened low titer donor at the POI.
This has been shown to be very effective, but it takes a trained responder
8–15 minutes to collect a single unit.
The second option involves collecting whole blood from low titer
donors the day before a mission, keeping it stored at 33. 8–42. 8 degrees F,
then carrying it on the mission in an
The third option is to ship the
FDA-licensed cold-stored LTOWB
to from ASBP Donation Centers to
operational units and combat hospitals in combat theaters. The third option is
the most feasible for civilian EMS providers.
WHY USE WHOLE BLOOD?
There are three reasons why whole blood is
ideal for prehospital use. First, whole blood is
superior to crystalloids and colloids. There’s
very little room to argue that crystalloid and
colloid fluids are appropriate in resuscitation.
The hazards of dilutional coagulopathy and
acidosis are well documented.
Second, whole blood administration is easier than the administration of components. The
administration of whole blood is the simplest
way to deliver the functionality of lost blood
back to the patient.
The Serious Hazards of Transfusion
(SHOT) study from the U.K. looked at the
serious hazards of transfusion and found that
approximately 78% of the incident reports
resulted from human error, despite there being
rules in place to improve practice.
Third, the safety of whole blood transfusions
is similar to component therapy, as T TD testing is completed for both. The U.S. military
has successfully transfused over 10,000 units
of whole blood across the world.
20 The body
of evidence will grow as more civilian agencies initiate their own whole blood programs.
WHOLE VS. COMPONENT
When blood components are made, whole
Table 1: Whole blood vs. components
Hematocrit (Hct) 35–37% 28%
Platelets 138–165 90–120
Normal at baseline,
FVIII ≥ 50% at day 7
All 62% dilution
at baseline, no FVIII
Clotting (TEG) Nearly normal day 21 Reduced vs. WB
PLT aggregation ≥ 50% baseline d7-10 Nearly complete loss d5 in RT-PLT
( 4 liters)
8 bags, one storage mode
( 8 U, 4000 mL)
13 bags, three storage
modes (6:6: 1, 4150 mL)
Adapted from Armand R, Hess JR. Treating coagulopathy in trauma patients. Transfus Med Rev. 2003; 17( 3):
223–231. Table courtesy Col. Andrew P. Cap, MD, PhD/United States Army Institute of Surgical Research
of whole blood is the
simplest way to deliver
the functionality of lost
blood back to the patient.