Original Research| Volume 41, ISSUE 5, P451-457, September 2022

Prehospital Use of Whole Blood for Ill and Injured Patients During Critical Care Transport



      Hemodynamic instability and hemorrhagic shock are frequently encountered by emergency medical services providers managing ill and injured patients during critical care transport. Although many critical care transport services commonly transfuse crystalloids and/or packed red blood cells (PRBCs), the administration of whole blood (WB) in prehospital care is currently limited. WB contains PRBCs, plasma, and platelets in a physiologic ratio to aid in oxygen delivery to tissue as well as hemostasis. This study describes a single critical care transport program's experience using WB for critically ill and injured patients and reports important clinical and safety outcomes.


      This study was a retrospective review of patients who were transported by a single rotor wing–based critical care transport service to 1 of 2 tertiary care receiving hospitals within a single health system. Patients who were transported between November 1, 2018, and November 30, 2019, and who received at least 1 unit of low-titer group O WB during critical care transport were included. The primary outcomes of interest included 24-hour mortality and the total 24-hour transfusion requirement. The safety outcomes included transfusion reactions, acute lung injury, acute kidney injury, and the incidence of venous thromboembolism.


      During the study period, there were 3,084 total patients transported by our critical care transport service. There were 71 patients who received prehospital WB, 64 of whom met the inclusion criteria. The top 3 indications for WB administration included blunt trauma (n = 27, 42.2%), gastrointestinal hemorrhage (n = 15, 23.4%), and penetrating trauma (n = 11, 17.2%). The median total number of blood components transfused within 24 hours was 4.0 (interquartile range, 2.0-9.5), and the overall 24-hour mortality rate was 21.9%.


      The administration of WB by emergency medical services providers to critically ill and injured patients in the prehospital setting is feasible and is associated with low incidences of adverse events and transfusion reactions. Further research is needed to elucidate the benefits of WB relative to current prehospital standards of care.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Air Medical Journal
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Kauvar DS
        • Lefering R
        • Wade CE
        Impact of hemorrhage on trauma outcome: an overview of epidemiology, clinical presentations, and therapeutic considerations.
        J Trauma. 2006; 60: S3-11
        • Eastridge BJ
        • Mabry RL
        • Seguin P
        • et al.
        Death on the battlefield (2001-2011): implications for the future of combat casualty care.
        J Trauma Acute Care Surg. 2012; 73: S431-S437
      1. Pyle H, Salazar G, Macy R, Fowler RL. Prehospital fluid management in hemorrhagic shock. JEMS. Accessed August 5, 2021.

        • American College of Surgeons, Committee on Trauma
        Advanced Trauma Life Support: Student Course Manual.
        10th ed. American College of Surgeons, Chicago, IL2018
        • Awad S
        • Allison SP
        • Lobo DN
        The history of 0.9% saline.
        Clin Nutr. 2008; 27: 179-188
        • Blumberg N
        • Cholette JM
        • Pietropaoli AP
        • et al.
        0.9% NaCl (normal saline) – perhaps not so normal after all?.
        Transfus Apher Sci. 2018; 57: 127-131
        • Ley EJ
        • Clond MA
        • Srour MK
        • et al.
        Emergency department crystalloid resuscitation of 1.5 L or more is associated with increased mortality in elderly and nonelderly trauma patients.
        J Trauma. 2011; 70: 398-400
        • 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.
        JAMA. 2015; 313: 471-482
        • Sperry JL
        • Guyette FX
        • Brown JB
        • et al.
        Prehospital plasma during air medical transport in trauma patients at risk for hemorrhagic shock.
        N Engl J Med. 2018; 379: 315-326
        • Murdock AD
        • Berseus O
        • Hervig T
        • et al.
        Whole blood: the future of traumatic hemorrhagic shock resuscitation.
        Shock. 2014; 41: 62-69
        • Shea SM
        • Staudt AM
        • Thomas KA
        • et al.
        The use of low-titer group O whole blood is independently associated with improved survival compared to component therapy in adults with severe traumatic hemorrhage.
        Transfusion. 2020; 60: S2-S9
        • Jones AR
        • Frazier SK
        Increased mortality in adult trauma patients transfused with blood components compared with whole blood.
        J Trauma Nurs. 2014; 21: 22-29
        • Braverman MA
        • Smith A
        • Pokorny D
        • et al.
        Prehospital whole blood reduces early mortality in patients with hemorrhagic shock.
        Transfusion. 2021; 61: S15-S21
        • Fisher AD
        • Miles EA
        • Broussard MA
        • et al.
        Low titer group O whole blood resuscitation: military experience from the point of injury.
        J Trauma Acute Care Surg. 2020; 89: 834-841
        • Roquet F
        • Neuschwander A
        • Hamada S
        • et al.
        Association of early, high plasma-to–red blood cell transfusion ratio with mortality in adults with severe bleeding after trauma.
        JAMA Netw Open. 2019; 2e1912076
        • Yazer MH
        • Jackson B
        • Sperry JL
        • et al.
        Initial safety and feasibility of cold-stored uncrossmatched whole blood transfusion in civilian trauma patients.
        J Trauma Acute Care Surg. 2016; 81: 21-26
        • Gallaher JR
        • Dixon A
        • Cockcroft A
        • et al.
        Large volume transfusion with whole blood is safe compared with component therapy.
        J Trauma Acute Care Surg. 2020; 89: 238-245
        • Williams J
        • Merutka N
        • Meyer D
        • et al.
        Safety profile and impact of low-titer group O whole blood for emergency use in trauma.
        J Trauma Acute Care Surg. 2020; 88: 87-93
        • Silver SA
        • Beaubien-Souligny W
        • Shah PS
        • et al.
        The prevalence of acute kidney injury in patients hospitalized with COVID-19 infection: a systematic review and meta-analysis.
        Kidney Med. 2021; 3: 83-98
        • Case J
        • Khan S
        • Khalid R
        • Khan A
        Epidemiology of acute kidney injury in the intensive care unit.
        Crit Car Res Pract. 2013; 2013479730
        • Summers C
        • Singh NR
        • Worpole L
        • et al.
        Incidence and recognition of acute respiratory distress syndrome in a UK intensive care unit.
        Thorax. 2016; 71: 1050-1051
        • Singh G
        • Gladdy G
        • Chandy TT
        • et al.
        Incidence and outcome of acute lung injury and acute respiratory distress syndrome in the surgical intensive care unit.
        Indian J Crit Care Med. 2014; 18: 659-665
        • Leeper CM
        • Yazer MH
        • Cladis FP
        • et al.
        Use of uncrossmatched cold-stored whole blood in injured children with hemorrhagic shock.
        JAMA Pediatr. 2018; 172: 491-492
        • Leeper CM
        • Yazer MH
        • Triulzi DJ
        • et al.
        Whole blood is superior to component transfusion for injured children: a propensity matched analysis.
        Ann Surg. 2020; 272: 590-594
        • Thottathil P
        • Sesok-Pizzini D
        • Taylor JA
        • et al.
        Whole blood in pediatric craniofacial reconstruction surgery.
        J Craniofac Surg. 2017; 28: 1175-1178
        • Leeper CM
        • Yazer MH
        • Morgan KM
        • et al.
        Adverse events after low titer group O whole blood versus component product transfusion in pediatric trauma patients: a propensity-matched cohort study.
        Transfusion. 2021; 61: 2621-2628
        • Morgan KM
        • Yazer MH
        • Triulzi DJ
        • et al.
        Safety profile of low-titer group O whole blood in pediatric patients with massive hemorrhage.
        Transfusion. 2021; 61: S8-S14
        • Alexander JM
        • Sarode R
        • McIntire DD
        • et al.
        Whole blood in the management of hypovolemia due to obstetric hemorrhage.
        Obstet Gynecol. 2009; 113: 1320-1326
        • Morris DS
        • Braverman MA
        • Corean J
        • et al.
        Whole blood for postpartum hemorrhage: early experience at two institutions.
        Transfusion. 2020; 60: S31-S35
        • Newberry R
        • Winckler CJ
        • Luellwitz R
        • et al.
        Prehospital transfusion of low-titer o+ whole blood for severe maternal hemorrhage: a case report.
        Prehosp Emerg Care. 2020; 24: 566-575