USE OF WHOLE BLOOD DURING RESUSCITATION

WB products

WB products listed from most to least preferred:

- Best: Low-titer group O whole blood (LTOWB) for all
  - Food and Drug Administration–compliant LTOWB supplied by the Armed Services Blood Program.
  - LTOWB drawn from prescreened donors at deployed location, either before mission or during combat casualty care.

- Identify LTOWB donors before deployment. Test all personnel with group O blood for anti-A and anti-B antibodies; low titer is defined as immunoglobulin M anti-A and anti-B ratio less than 1:256.

- Test for transfusion transmitted diseases (TTDs) before deployment and maintain a roster of donors while deployed. Repeat TTD testing every 90 to 120 days when possible.

- If adequate staff available, confirm ABO group of LTOWB donor prior to transfusing patient using Eldon card or other approved ABO testing kit. If the wrong blood group is transfused, there is a possibility of fatal transfusion reaction.

- Better: Administer group-specific WB from prescreened donors
  - Group A to group A, group O to group O and LTOWB for group B and group AB.
  - Group specific for all ABO Group
  - The ABO group of the patient must be confirmed using Eldon card or other approved ABO testing kit. If the wrong blood group is transfused, there is a possibility of fatal transfusion reaction.
- Minimum: when prescreened donors for LTOWB or group-specific WB are not available, identify unscreened donors using an Eldon card or other approved ABO testing kit. If the need arises to use blood from unscreened donors. See Appendix B.
  - Group specific (if adequate staff are available, perform testing and verify with second round of testing; i.e. two Eldon cards by two providers for both donor and recipient to be sure that groupings are correct; if the wrong blood group is transfused, there is a possibility of fatal transfusion reaction).
  - If adequate staff or supplies not available or in chaotic situations, use group O for any patient (possibility of transfusion reaction if not titer tested; however, less likely to result in acute hemolytic transfusion reaction than mistaken group-specific transfusion).

Note: If blood-group testing has not been performed on the casualty before receiving LTOWB, it may not be possible to establish the underlying blood group and they should only receive universal donor blood products. Every effort should be made to obtain a blood sample for later typing before transfusion of LTOWB.

When WB cannot be obtained, resuscitation using blood products should proceed according to the order of priority for fluid administration, targeting an equal balance of all blood products that are available (RBCs, plasma, platelets).

Transfusion notes

- If time and staffing permit, utilize rapid TTD test kits when prescreened donors are not available. Priority for testing should be for HIV and/or any disease of high significance in local area for which test kits are available.
- During resuscitation, blood products and fluids should be warmed using a fluid warmer and infused rapidly.
- WB can be collected and transfused as warm, fresh whole blood (WFWB) or cold-stored whole blood (CS-WB). CS-WB will almost always be LTOWB. See WB CPG for more details.28
- WFWB may have some advantages for resuscitation in the PFC environment when prescreened donors are available and the tactical situation allows, because WFWB may be associated with improved survival in trauma patients.3,4,29 However, CS-WB is more completely tested for infectious disease and does not require additional personnel to collect or donate the blood, and should be used preferentially when available.
- Blood and blood products should only be administered by personnel who are trained in the proper procedure and the identification and management of transfusion reactions.
- Usually only one unit of FWB should be collected per donor. However, in extremis, two units may be taken from a single donor. Depending on the size and physical fitness of the donor, a two-unit collection may degrade the tactical performance of a donor, whereas a single unit collection will not. If a second unit is collected from the same donor, consider evacuating the donor with the casualty.
- Freeze-dried plasma (FDP) may be administered to initiate resuscitation while obtaining FWB and/or moving the casualty to a location where blood products are available. The indications to give FDP are the same as the indications for transfusion. FDP is a universal blood product that can be given to any blood group.
- See Appendix A for a summary of blood products provided by the Armed Services Blood Program.