Skip to main content
SpringerLink
Log in

Prehospital Resuscitation with Low Titer O+ Whole Blood by Civilian EMS Teams: Rationale and Evolving Strategies for Use

  • Chapter
  • First Online:
Annual Update in Intensive Care and Emergency Medicine 2020

Part of the book series: Annual Update in Intensive Care and Emergency Medicine ((AUICEM))

Abstract

Uncontrolled severe bleeding due to injury or other non-traumatic causes is a major cause of premature death worldwide. Although control of anatomic hemorrhage sites, internally or externally, is always the priority, replacement of lost blood often can be delayed until definitive surgical intervention. Transfusions generally are not provided before arriving at the medical receiving facility where traditional blood-typing and crossmatching can be accomplished. With the intent of providing hemodynamic support in the preoperative setting, other strategies evolved over the past half-century, including infusion of volume-expanding intravascular fluids that are not blood-based. Becoming a standard of care for many years, there are now growing concerns about early resuscitation with crystalloids and other fluids that are not blood-based. Beyond the lack of oxygen-carrying capacity in the face of active uncontrolled bleeding, there are also substantial concerns about accelerating hemorrhage hydraulically, disrupting intrinsic clotting functions, and unrecognized creation of an endotheliopathy. In contrast, there is a growing rationale and evolving evidence that bringing whole blood to the civilian prehospital setting is not only feasible but also superior to the typical hospital-based component therapy approach. Based on various preliminary studies, the use of cold-stored, rapidly rewarmed low titer O+ whole blood already appears to be a potentially lifesaving intervention that also mitigates endotheliopathy as well as concerns regarding transfusion reactions. Several strategic initiatives have now been created to help to facilitate sustainable sourcing and placement of cold-stored low titer O+ whole blood, even on ground-based ambulance units.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 109.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 139.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Pantridge JF, Geddes JS. A mobile intensive care unit in the management of myocardial infarction. Lancet. 1967;290:271–3.

    Article  Google Scholar 

  2. Cobb LA, Alvarez H, Copass MK. A rapid response system for out-of-hospital cardiac emergencies. Med Clin North Am. 1976;60:283–93.

    Article  CAS  Google Scholar 

  3. McManus WF, Tresch DD, Darin JC. An effective prehospital emergency system. J Trauma. 1977;17:304–10.

    Article  CAS  Google Scholar 

  4. Page JO. The paramedics: an illustrated history of paramedics in their first decade in the U.S.A. Morristown, NJ: Backdraft Publications; 1979. p. 1–179.

    Google Scholar 

  5. Pepe PE, Copass MK, Fowler RL, Racht EM. Medical direction of emergency medical services systems. In: Cone DC, Fowler R, O’Connor RE, editors. Emergency medical services: clinical practice and systems oversight. Dubuque, IA: Textbook of the National Association of EMS Physicians, Kendall Hunt Publications; 2009. p. 22–52.

    Google Scholar 

  6. American College of Surgeons Committee on Trauma. Advanced trauma life support program for physicians. 6th ed. Chicago, IL: American College of Surgeons; 1997. p. 21–124.

    Google Scholar 

  7. Bickell WH, Pepe PE, Bailey ML, et al. Randomized trial of pneumatic anti-shock garments in the prehospital management of penetrating abdominal injury. Ann Emerg Med. 1987;16:653–8.

    Article  CAS  Google Scholar 

  8. Bickell WH, Wall MJ, Pepe PE, et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injury. N Engl J Med. 1994;331:1105–9.

    Article  CAS  Google Scholar 

  9. Wiggers C. Physiology of shock. New York, NY: Commonwealth Fund; 1950. p. 121–46.

    Google Scholar 

  10. Shires T, Coln D, Carrico CJ, et al. Fluid therapy in hemorrhagic shock. Arch Surg. 1964;88:688–93.

    Article  CAS  Google Scholar 

  11. Mattox KL, Maningas PA, Moore EE, et al. Prehospital hypertonic saline/dextran infusion for post-traumatic hypotension—the U.S.A. multi-center trial. Ann Surg. 1991;213:482–91.

    Article  CAS  Google Scholar 

  12. Bickell WH, Bruttig SP, Millnamow GA, et al. The detrimental effects of intravenous crystalloid after aortotomy in swine. Surgery. 1991;110:529–36.

    PubMed  CAS  Google Scholar 

  13. Capone A, Safar P, Stezoski W, et al. Improved outcome with fluid restriction in treatment of uncontrolled hemorrhagic shock. J Am Coll Surg. 1995;180:49–56.

    PubMed  CAS  Google Scholar 

  14. Stern SA, Zink BJ, Mertz M, Wang Z, Dronen SC. Effect of initially limited resuscitation in a combined model of fluid-percussion brain injury and severe uncontrolled hemorrhagic shock. J Neurosurg. 2000;93:305–14.

    Article  CAS  Google Scholar 

  15. Owens TM, Watson WC, Prough DS, et al. Limiting initial resuscitation of uncontrolled hemorrhage reduces internal bleeding and subsequent volume requirements. J Trauma. 1995;39:200–7.

    Article  CAS  Google Scholar 

  16. Rafie AD, Rath PA, Michell MW, et al. Hypotensive resuscitation of multiple hemorrhages using crystalloid and colloids. Shock. 2004;22:262–9.

    Article  Google Scholar 

  17. Shoemaker WC, Peitzman AB, Bellamy R, et al. Resuscitation from severe hemorrhage. Crit Care Med. 1996;24:S12–23.

    Article  CAS  Google Scholar 

  18. Dutton RP, Mackenzie CF, Scalea T. Hypotensive resuscitation during active hemorrhage: impact on in-hospital mortality. J Trauma. 2002;52:1141–6.

    Article  Google Scholar 

  19. Meuer WJ. Tranexamic acid reduced mortality in trauma patients who were bleeding or at risk for bleeding. Ann Intern Med. 2013;159:JC3.

    Article  Google Scholar 

  20. Holcomb JB, Jenkins D, Rhee P, et al. Damage control resuscitation: directly addressing the early coagulopathy of trauma. J Trauma. 2007;62:307–10.

    Article  Google Scholar 

  21. Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA. 2015;313:471–82.

    Article  CAS  Google Scholar 

  22. Sperry JL, Guyette FX, Brown JB, et al. Prehospital plasma during air medical transport in trauma patients at risk for hemorrhagic shock (PAMPer Study Group). N Engl J Med. 2018;379:315–26.

    Article  Google Scholar 

  23. Morte D, Lammers D, Bingham J, Kuckelman J, Eckert M, Martin M. Tranexamic acid administration following head trauma in a combat setting: does tranexamic acid result in improved neurological outcomes? J Trauma Acute Care Surg. 2019;87:125–9.

    Article  CAS  Google Scholar 

  24. Roberts I, Shakur-Still H, Aeron-Thomas A, et al, writing group for the CRASH-2 Trial Collaborators. Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH-3): a randomized, placebo-controlled trial. Lancet. 2019;394:1713–23.

    Google Scholar 

  25. Woolley T, Thompson P, Kirkman E, et al. Trauma hemostasis and oxygenation research network position paper on the role of hypotensive resuscitation as part of remote damage control resuscitation. J Trauma Acute Care Surg. 2018;84(suppl):S3–S13.

    Article  Google Scholar 

  26. Holcomb JB, Pati S. Optimal trauma resuscitation with plasma as the primary resuscitative fluid: the surgeon’s perspective. Hematology Am Soc Hematol Educ Program. 2013;1:656–9.

    Article  Google Scholar 

  27. Zhu CS, Pokorny DM, Eastridge B, et al. Give the patient what they bleed, when and where they need it: establishing a comprehensive regional system of resuscitation based on patient need utilizing cold-stored, low titer O+ whole blood. Transfusion. 2019;59:1429–38.

    Article  Google Scholar 

  28. Weymouth W, Long B, Koyfman A, Winckler CJ. Whole blood in trauma: a review for the emergency clinicians. J Emerg Med. 2019;56:491–8.

    Article  Google Scholar 

  29. Schott U, Solomon C, Fries D, Bentzer P. The endothelial glycocalyx and its disruption, protection and regeneration: a narrative review. Scand J Trauma Resusc Emerg Med. 2016;24:48.

    Article  Google Scholar 

  30. Guyette FX, Sperry JL, Peitzman AB, et al. Prehospital blood product and crystalloid resuscitation in the severely injured patient: a secondary analysis of the prehospital air medical plasma trial. Ann Surg. 2019 April 13. https://doi.org/10.1097/SLA.0000000000003324. [Epub ahead of print].

  31. Moore HB, Moore EE, Chapman MP, et al. Plasma-first resuscitation to treat haemorrhagic shock during emergency ground transportation in an urban area: a randomised trial. Lancet. 2018;392:283–91.

    Article  Google Scholar 

  32. Jones AR, Frazier SK. Increased mortality in adult patients with trauma transfused with blood components compared with whole blood. J Trauma Nurs. 2014;21:22–9.

    Article  Google Scholar 

  33. Pidcoke HF, Aden JK, Mora AG, et al. Ten-year analysis of transfusion in operation Iraqi Freedom and operation Enduring Freedom: increased plasma and platelet use correlates with improved survival. J Trauma Acute Care Surg. 2012;73(6 Suppl 5):S445–52.

    Article  Google Scholar 

  34. Spinella PC, Perkins JG, Grathwohl KW, Beekley AC, Holcomb JB. Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries. J Trauma. 2009;66(4 suppl):S69–76.

    Article  Google Scholar 

  35. Spinella PC, Pidcoke HF, Strandenes G, et al. Whole blood for hemostatic resuscitation of major bleeding. Transfusion. 2016;56:S190–202.

    Article  Google Scholar 

  36. Strandenes G, Berseus O, Cap AP, et al. Low titer group O whole blood in emergency situations. Shock. 2014;41(Suppl 1):70–5.

    Article  Google Scholar 

  37. Berséus O, Boman K, Nessen SC, Westerberg LA. Risks of hemolysis due to anti-A and anti-B caused by the transfusion of blood or blood components containing ABO-incompatible plasma. Transfusion. 2013;53:114S–23S.

    Article  Google Scholar 

  38. Porter TF, Silver RM, Jackson GM, Branch DW, Scott JR. Intravenous immune globulin in the management of severe Rh D hemolytic disease. Obstet Gynecol Surv. 1997;52:193–7.

    Article  CAS  Google Scholar 

  39. Reed W, Lee T-H, Norris PJ, Utter GH, Busch MP. Transfusion associated microchimerism: a new complication of blood transfusions in severely injured patients. Semin Hematol. 2007;44:24–31.

    Article  Google Scholar 

  40. McGinity AC, Zhu CS, Greebon L, et al. Prehospital low-titer cold stored whole blood: philosophy for ubiquitous utilization of O-positive product for emergency use in hemorrhage due to injury. J Trauma Acute Care Surg. 2018;84(6s Suppl):S115–9.

    Article  Google Scholar 

  41. Newberry R, Winckler CJ, Luellwitz R, Greebon L, Xenakis E, Bullock W, Stringfellow M, Mapp J. Prehospital transfusion of low-titer O+ whole blood for severe maternal hemorrhage: a case report. Prehosp Emerg Care. 2019 Oct 14; https://doi.org/10.1080/10903127.2019.1671562. [Epub ahead of print].

Download references

Author information

Authors and Affiliations

  1. Dallas County EMS and Public Safety Operations, Fire Marshal’s Office, Dallas, TX, USA

    P. E. Pepe

  2. The Broward Sheriff’s Office Department of Fire Rescue and Air Rescue, Fort Lauderdale, FL, USA

    P. E. Pepe & J. P. Roach

  3. The City of San Antonio Fire Department Emergency Medical Services, San Antonio, TX, USA

    C. J. Winckler

  4. Departments of Emergency Health Science and Emergency Medicine, The University of Texas Health Science Center, San Antonio, TX, USA

    C. J. Winckler

Authors
  1. P. E. Pepe
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. J. P. Roach
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. C. J. Winckler
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to P. E. Pepe .

Editor information

Editors and Affiliations

  1. Department of Intensive Care, Erasme University Hospital, Université libre de Bruxelles, Brussels, Belgium

    Jean-Louis Vincent

Rights and permissions

Reprints and permissions

Copyright information

© 2020 Springer Nature Switzerland AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Pepe, P.E., Roach, J.P., Winckler, C.J. (2020). Prehospital Resuscitation with Low Titer O+ Whole Blood by Civilian EMS Teams: Rationale and Evolving Strategies for Use. In: Vincent, JL. (eds) Annual Update in Intensive Care and Emergency Medicine 2020. Annual Update in Intensive Care and Emergency Medicine. Springer, Cham. https://doi.org/10.1007/978-3-030-37323-8_29

Download citation

  • DOI: https://doi.org/10.1007/978-3-030-37323-8_29

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-37322-1

  • Online ISBN: 978-3-030-37323-8

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation