Enhanced Military Blood Transfusion Protocols Have Potential to Improve Civilian Care

Protocols allowing for efficient delivery of red blood cells and fresh frozen plasma in combat may increase survival.

New military trauma care protocols for treating hemorrhage and resuscitation on combat zone front lines may improve emergency care if implemented in civilian trauma care centers as well, according to research published in the AANA Journal.

David Gaskin, CRNA, MHS, staff anesthetist at Huntsville Memorial Hospital in Huntsville, Texas, and colleagues examined two case studies of treatments performed by a Forward Surgical Team serving in Afghanistan during Operation Enduring Freedom in 2014. The researchers examined these cases to make recommendations for changes to the current transfusion strategy.

In the military and some civilian facilities, transfusion of packed red blood cells (PRBC) and fresh frozen plasma (FFP) is performed in a 1:1 ratio. Although several studies have shown that 1:1 ratios of transfusion are associated with improved 24-hour and 30-day survival rates with adherence to a massive blood transfusion (MT) protocol, this is not a universally accepted approach in most civilian institutions.

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Due to difficulties with thawing FFP in combat zones, delays can prevent clinicians from being able to quickly administer a sufficient quantity of blood to trauma patients. While PRBCs are maintained at 4°C and are immediately available in large quantities, FFP is stored at -20°C,  and thawing requires 30 minutes in a warmer. Because FFP is stored in thin plastic bags, approximately 25% will break during thawing, making the product unusable. If this breakage is not discovered until late in the thaw cycle, preparation of the next unit is greatly delayed, and the rate of infusion can easily outpace the rate of thawing.

Problems communicating with live blood donors on site can also cause delays in obtaining fresh blood supplies, and incorrect tourniquet technique can reduce the amount of blood drawn from donors.

All of these issues contributed to the death of the patient in the first case study. Members of the surgical team were unable to infuse PRBCs and FFP in the correct ratio or in a timely manner, nor were they able to infuse an adequate quantity of fresh whole blood. This led to the lethal triad of coagulopathy, acidosis, and hypothermia.

Reviewing this case study resulted in to several improved protocol changes:

  • Keep 4 units of FFP thawed and ready for immediate use at all times, with additional FFP thawed as soon as the original FFP order was requested.
  • Instruct laboratory technicians to examine thawing FFP every 5 minutes to quickly identify and replace any that had broken.
  • Train all medics involved with drawing blood from donors in correct tourniquet technique.
  • Identify and prescreen additional donors and implement a phone roster and basewide overhead system to increase the speed of acquiring additional blood supplies.

The patient from the second case study sustained injuries of similar severity, but the revised protocols greatly aided in his survival. “Early and aggressive use of fresh whole blood and plasma provided the necessary endogenous clotting factors and platelets to promote hemostasis in the setting of massive blood transfusion,” wrote Mr Gaskin.

The researchers note that more research on trauma, coagulopathy, and hemorrhage is needed. “Much research is under way, but freeze-dried products and concentrates should be recognized as possible valuable options in the austere conditions of combat and in the civilian hospital,” wrote Dr Gaskin. “This area of research should be of paramount importance to the civilian trauma community.”


Gaskin D, Kroll NA, Ochs AA, et al. Far forward anesthesia and massive blood transfusion: two cases revealing the challenge of damage control resuscitation in an austere environment. AANA J. 2015;83(5):337-343.