Whole Blood: Ready for Primetime?

If you’ve been reading about trauma care in the last few years, you have undoubtedly
seen something about the use of whole blood in trauma resuscitation. Born out of
military medicine experience, we are starting to see civilian EMS programs in both air
and ground using this treatment to save lives from traumatic injury and massive

But what exactly is going on? Why is there a benefit to giving whole blood in the field,
and aren’t there plenty of reasons why we can’t do it in my shop? You may be
surprised that the future is the past, and it’s more attainable than ever.
In the First World War, the preferred resuscitation fluid was whole blood. Through the
years, we’ve seen a change to plasma, crystalloid, and then 1:1:1 therapy. Each
method had its weaknesses, either physiologic or logistic, and researchers saw
increasingly negative outcomes with each change in medical thought. Conditions like
Da Nang Lung or “shock lung” (now known as ARDS) and abdominal compartment
syndrome skyrocketed in military medicine as whole blood was abandoned for fluids like
saline and lactated Ringer’s.

In 1993, a soldier who a shark attacked off the beaches of Mogadishu, Somalia,
became a test case using a “walking blood bank.” The lack of blood products led
to the use of emergency donor collection, which proved instrumental to his survival (1).
The concept was also placed into use during the subsequent Battle of Mogadishu.
The military proved there were significant survival benefits from the use of whole blood.
Although walking blood banks may not be feasible in the civilian world, the evidence
points to the benefit of storing whole blood in trauma.

The current standard of care for hemorrhage in civilian EMS is to administer
crystalloids, either lactated Ringer’s or saline solution. While the thought process has
progressed to embrace damage control resuscitation, and most paramedics will tell you
that they limit the administration of crystalloid to patients with a MAP above 65mmHg,
some texts and classes still advise the use of up to 1 liter of crystalloid before using

There are a lot of problems with giving crystalloids to bleeding patients. Giving saline or
Ringer’s to actively bleeding patients can cause everything from increased acidosis and
coagulopathy to later complications like abdominal compartment syndrome and cerebral
edema. Also, the administration of room temperature or, worse, cold IV fluid to these
patients can cause hypothermia and exacerbate the inability to form a clot effectively.
All of these complications can cause a significant increase in morbidity and mortality.
Why is giving a unit of whole blood such a “force multiplier” in actively bleeding
patients? The answer is inside.

Because of the way it is preserved and stored, 1:1:1 therapy has a much lower hematocrit, platelet count, and concentration of clotting factors (2). Yes, it will carry oxygen; but it has less of the exact things the trauma patient is losing and needs to survive. On the other hand, one unit of whole blood contains a more normal hematocrit and platelet count and has all critical clotting factors. While 1:1:1 therapy or giving PRBCs or plasma alone is better than crystalloid, whole blood is preferable and may have more of a survival benefit for patients.

The future is happening now. In San Antonio and New Orleans, low titer O whole blood
can now be administered to bleeding patients in the field. Notably, both areas
are built-up, urban areas with trauma centers accessible by ground EMS. The
conventional thought would be to forego blood and transport it to the trauma bay. But
the data from New Orleans suggests that the earlier we administer blood to sick
trauma patients, the better the outcome.

What about the logistics of a whole blood program? In San Antonio, TX, a regional group
of stakeholders have devised a system to return whole blood to the trauma centers to
be used as components, extending the useful life of the blood. The current waste rate
for the program is around 1-2%, and they have sponsored public outreach to find low-titer type O donors (4).

The paradigm of prehospital care is changing. No longer are we trapped in the binary
“load-and-go” or “stay-and-play” mindset. Today’s paramedicine is an investment in time
for the patient’s ultimate benefit. Prehospital interventions like whole blood can be used
to buy time for definitive care and, ultimately, surgical intervention. It’s time for evidence-based treatments to become the priority.

  1. Thompson, P., & Strandenes, G. (2019). The History of Fluid Resuscitation for
    Bleeding. Damage Control Resuscitation: Identification and Treatment of LifeThreatening Hemorrhage, 3–29. https://doi.org/10.1007/978-3-030-20820-2_1
  2. Ponschab, M., Schöchl, H., Gabriel, C., Süssner, S., Cadamuro, J., HaschkeBecher, E., Gratz, J., Zipperle, J., Redl, H., & Schlimp, C. J. (2015). Haemostatic
    profile of reconstituted blood in a proposed 1:1:1 ratio of packed red blood cells,
    platelet concentrate and four different plasma preparations. Anaesthesia, 70(5),
    528–536. https://doi.org/10.1111/anae.13067
  3. Schaefer, R., Long, T., Wampler, D., Summers, R., Epley, E., Waltman, E.,
    Eastridge, B., & Jenkins, D. (2021). Operationalizing the deployment of low-titer O-
    positive whole blood within a regional trauma system. Military Medicine,
    186(Supplement_1), 391–399. https://doi.org/10.1093/milmed/usaa283
  4. Pokorny, D. M., Braverman, M. A., Edmundson, P. M., Bittenbinder, D. M., Zhu, C.
    S., Winckler, C. J., Schaefer, R., McGinity, A. C., Epley, E., Eastridge, B. J.,
    Nicholson, S. E., Stewart, R. M., & Jenkins, D. H. (2019). The use of prehospital
    blood products in the resuscitation of trauma patients: A review of prehospital
    transfusion practices and a description of our regional whole blood program in San
    Antonio, tx. ISBT Science Series, 14(3), 332–342.

Daniel Schwester

Daniel Schwester, MICP

Dan is Managing Partner and Chief Operating Officer of Overrun Productions, LLC; and a co-host of The Overrun Podcast. He has been involved in EMS and prehospital care for over 20 years in a wide range of roles, including street-level provider, field training officer, education, and clinical management. He is currently a Paramedic Preceptor for a large progressive EMS agency located on the East Coast of the USA. Dan is passionate about airway management, clinical exam skills, human factors, teaching, and traveling in his spare time.

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