This injury pattern mandates immediate activation of massive transfusion protocol with the preferential use of whole blood and no crystalloid as part of the resuscitation. If there is prior notification of a DCBI casualty, warm whole blood should be ready to transfuse on a rapid transfuser (Belmont or Level 1) prior to the casualty arriving. A good starting formula for transfusion requirement is 8 units of whole blood for each above knee amputation (AKA). Thus, a casualty with bilateral AKAs should have 16 units of whole blood, or 16 red blood cells (RBCs), 16 fresh frozen plasma, and 3 units of platelets ready to transfuse in the first 60 minutes of presentation. Teams that do not have this blood supply should activate the WBB. If the casualty’s blood type can be tested and there is the appropriate manpower and administrative support, then a type-specific WBB should be activated. If there are multiple casualties or if the recipient’s blood type is not known, then a LTOWB WBB should be activated.

Data from the DoDTR on 385 casualties from 2010-2021 with bilateral lower extremity amputations secondary to DCBI were transfused an average of 45 units of blood in the first 24 hours, with the highest volume of blood recorded in a survivor from this injury being over 200 units of blood product. This underscores the imperative that massive (>10 units of PRBCs/WB in 24 hours) and ultra-massive transfusion (>20 units of PRBCs/WB in 24 hours) are necessary for these casualties to survive.

These casualties are resource intensive, and time to resuscitation is critical if they are to survive. While it is understood at the time of the update of this clinical practice guidance (CPG), that the DOD is preparing for large scale combat operations (LSCO), if during the next conflict, multiple DCBI casualties are generated daily, the resources required to care for these casualties will test every aspect of the trauma system including field care and evacuation, blood supply, OR resources, personnel resources, and the movement from the theater of operations. This CPG outlines the optimal clinical management of these patients with the understanding that one of these patients will keep many providers in a well-equipped Role 3 busy for hours. The reality of the number of resources and care these casualties require must be recognized and triaged as appropriate for the operational and clinical scenario. If the trauma system is resourced appropriately for the demand signal, then these injuries, while devastating are survivable with early hemorrhage control (tourniquets), massive transfusion, and transport to a surgical capability. The role for early (and effective) tourniquets and blood products cannot be overemphasized. Minutes matter for survival for these injuries.

(Refer to JTS Damage Control Resuscitation (DCR) and Whole Blood Transfusion CPGs for further guidance on the resuscitation.5,6)