hemolytic reaction after the first exposure and
is nearly irrelevant in the emergency prehospital setting. According to the American Red
Cross, 10-20% of the U.S. population does not
have the Rh D antigen on the surface of their
red blood cells, also known as Rh “negative.”
After exposure to Rh “positive” blood, around
20-26% will develop a sensitivity within four
weeks. However, only 3-4% will develop a
strong immune response to future administration.
25 Although it’s common practice to
give women of childbearing age Rh-negative
blood, if it isn’t available, Rh-positive whole
blood should be transfused as it’s still preferred
over colloid or crystalloid infusion.
INCORPORATING WHOLE BLOOD
As previously stated, bolus of crystalloids and
colloids can increase mortality and has no
effective treatment in trauma. The current
recommendation of 1:1: 1 has three times the
anticoagulants and additives.
23 These additional additives can contribute to trauma-in-duced coagulopathy.
In late August 2017, Harris County Emergency Services District No. 48 (HCESD 48)
Fire Department and Cypress Creek EMS
(CCEMS) in Houston, Texas, began carrying
cold-stored LTOWB for hemostatic resuscitation. Before this unconventional approach,
both services had been carrying RBCs and
fresh plasma since mid-2016. There were over
100 units transfused, and currently work is
underway to obtain patient outcome data for
publication. Both services are use a response
vehicle with a paramedic who delivers blood
and oversees its storage. The protocol’s inclusion criteria is 12 and older (should have two
or more of the following):
>>Hemodynamically unstable (i.e., HR > 120;
systolic B/P ≤ 90 mmHg);
>>Penetrating injury or blunt trauma with significant injury;
>>Positive focused assessment with sonography
in trauma test (if available); and
If criteria aren’t met, and providers feel the
patient meets the threshold, HCESD 48 Fire
Department peronnel are advised to contact
the on-call medical director. CCEMS super-
visors can give it at their descretion based on
This established protocol was coordinated
through the HCESD 48 Fire Department
EMS chiefs, CCEMS Director of Special
Operations John Holcomb, MD, and the Gulf
Coast Regional Blood Center.
Due to the shorter shelf life of LTOWB,
there’s a higher potential for waste. In the
future, it may be possible to make component therapy from the unused LTOWB units.
This new protocol has the potential to influence many EMS systems and the transfusion
of whole blood in the prehospital setting has
the potential to save many lives. JEMS
Max Dodge, BS, NRP, EMT-P, is a paramedic and wilderness
medicine instructor in New Hampshire. He serves in the Army
National Guard as a Flight Paramedic and Medical Section Chief.
Dominic Thompson, EMT-P, is a 68W assigned to AMEDD
C&S Army EMS Programs Management Division. Previously
assigned to 3d Special Forces Group (Airborne) as a Special
Operations Combat Medic (SOCM).
Eric A. Bank, LP, NRP, graduated from the EMS management
program at Hahnemann University in 1996, and worked as a
paramedic until 2002. He became an EMS director in West
Harris County (Texas) EMS in 2002. In late 2009, he became
assistant chief of EMS at Harris County Emergency Services
District. He also serves as the Chair for the South East Regional
Advisory Council’s Trauma Committee.
Wren Nealy, LP, is the director of special operations for Cypress
Creek ( Texas) EMS and the vice chair of the Emergency Services Sector Coordiniating Council for the U.S. Department
of Homeland Security.
Andrew D. Fisher, MPAS, PA-C, is a second year medical stu-
dent at Texas A&M College of Medicine, a Tillman Scholar, and
physician assistant in the Texas Army National Guard. He was
previously assigned to the 75th Ranger Regiment.
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