The effectiveness of the manual pressure points technique for hemorrhage control-The 2022 THOR pre-conference meeting experience.

INTRODUCTION: Limb and junctional hemorrhage are leading causes of potentially preventable death among trauma casualties. Hemorrhage control for these regions could be achieved by direct or indirect pressure. The manual pressure points (MPP) involves applying manual pressure on the arterial supply to occlude distal blood flow without the need for specialized equipment. STUDY DESIGN AND METHODS: Prospective, non-randomized, human volunteer, controlled environment study involving 38 healthy military caregivers, with 26 participants attending a short instructional session. During a medical exercise, participants were requested to apply pressure on the supraclavicular and femoral points aiming to stop regional blood flow, measured by distal pulse palpation. The measures recorded included achievement of distal pulse cessation, success in achieving cessation for a full minute, and subjects' pain scores reported after each attempt. RESULTS: All participants succeeded in achieving distal pulse cessation for both the supraclavicular and femoral points for a full minute. The median time to initial success was 3.0 (interquartile range 2.0-5.0) seconds in the supraclavicular point and 4.5 (interquartile range 3.0-6.0) seconds in the femoral point. Pain scores ranging between 0 and 3 were reported by most subjects during supraclavicular (68.4%) and femoral occlusion (84.2%). CONCLUSION: The MPP technique was highly effective in occluding distal palpable pulses in healthy volunteers when applied to the supraclavicular and femoral arteries. Brief instruction on the technique can potentially improve the chances of achieving hemorrhage control within 5 s. Further research is required to determine efficacy among different populations and providers with varying experience levels.

Risk of Harm in Needle Decompression for Tension Pneumothorax.

INTRODUCTION: Tension pneumothorax (TPX) is the third most common cause of preventable death in trauma. Needle decompression at the fifth intercostal space at anterior axillary line (5th ICS AAL) is recommended by Tactical Combat Casualty Care (TCCC) with an 83-mm needle catheter unit (NCU). We sought to determine the risk of cardiac injury at this site. METHODS: Institutional data sets from two trauma centers were queried for 200 patients with CT chest. Inclusion criteria include body mass index of =30 and age 18-40 years. Measurements were taken at 2nd ICS mid clavicular line (MCL), 5th ICS AAL and distance from the skin to pericardium at 5th ICS AAL. Groups were compared using Mann-Whitney U and chi-squared tests. RESULTS: The median age was 27 years with median BMI of 23.8 kg/m2. The cohort was 69.5% male. Mean chest wall thickness at 2nd ICS MCL was 38-mm (interquartile range (IQR) 32-45). At 5th ICS AAL, the median chest wall thickness was 30-mm (IQR 21-40) and the distance from skin to pericardium was 66-mm (IQR 54-79). CONCLUSION: The distance from skin to pericardium for 75% of patients falls within the length of the recommended needle catheter unit (83-mm). The current TCCC recommendation to "hub" the 83mm needle catheter unit has potential risk of cardiac injury.

Implementation of a low-titre whole blood transfusion program in a civilian helicopter emergency medical service.

BACKGROUND: Early balanced transfusion is associated with improved outcome in haemorrhagic shock patients. This study describes the implementation and evaluates the safety of a whole blood transfusion program in a civilian helicopter emergency medical service (HEMS). METHODS: This prospective observational study was performed over a 5-year period at HEMS-Bergen, Norway. Patients in haemorrhagic shock receiving out of hospital transfusion of low-titre Group O whole blood (LTOWB) or other blood components were included. Two LTOWB units were produced weekly and rotated to the HEMS for forward storage. The primary endpoints were the number of patients transfused, mechanisms of injury/illness, adverse events and survival rates. Informed consent covered patient pathway from time of emergency interventions to last endpoint and subsequent data handling/storage. RESULTS: The HEMS responded to 5124 patients. Seventy-two (1.4%) patients received transfusions. Twenty patients (28%) were excluded due to lack of consent (16) or not meeting the inclusion criteria (4). Of the 52 (100%) patients, 48 (92%) received LTOWB, nine (17%) received packed red blood cells (PRBC), and nine (17%) received freeze-dried plasma. Of the forty-six (88%) patients admitted alive to hospital, 35 (76%) received additional blood transfusions during the first 24 h. Categories were blunt trauma 30 (58%), penetrating trauma 7 (13%), and nontrauma 15 (29%). The majority (79%) were male, with a median age of 49 (IQR 27-70) years. No transfusion reactions, serious complications or logistical challenges were reported. Overall, 36 (69%) patients survived 24 h, and 28 (54%) survived 30 days. CONCLUSIONS: Implementing a whole blood transfusion program in civilian HEMS is feasible and safe and the logistics around out of hospital whole blood transfusions are manageable. Trial registration The study is registered in the ClinicalTrials.gov registry (NCT02784951).

A whole blood based resuscitation strategy in civilian medical services: Experience from a Norwegian hospital in the period 2017-2020.

BACKGROUND: Civilian and military guidelines recommend early balanced transfusion to patients with life-threatening bleeding. Low titer group O whole blood was introduced as the primary blood product for resuscitation of massive hemorrhage at Haukeland University Hospital, Bergen, Norway, in December 2017. In this report, we describe the whole blood program and present results from the first years of routine use. STUDY DESIGN AND METHODS: Patients who received whole blood from December 2017 to April 2020 were included in our quality registry for massive transfusions. Post-transfusion blood samples were collected to analyze isohemagglutinin (anti-A/-B) and hemolysis markers. Administration of other blood products, transfusion reactions, and patient survival (days 1 and 30) were recorded. User experiences were surveyed for both clinical and laboratory staff. RESULTS: Two hundred and five patients (64% male and 36% female) received 836 units in 226 transfusion episodes. Patients received a mean of 3.7 units (range 1-35) in each transfusion episode. The main indications for transfusion were trauma (26%), gastrointestinal (22%), cardiothoracic/vascular (18%), surgical (18%), obstetric (11%), and medical (5%) bleeding. There was no difference in survival between patients with blood type O when compared with non-group O. Haptoglobin level was lower in the transfusion episodes for non-O group patients, however no clinical hemolysis was reported. No patients had conclusive transfusion-associated adverse events. Both clinical and laboratory staff preferred whole blood to component therapy for massive transfusion. DISCUSSION: The experience from Haukeland University Hospital indicates that whole blood is feasible, safe, and effective for in-hospital treatment of bleeding.

Prehospital Whole Blood Transfusion Programs in Norway.

BACKGROUND: Prehospital management of severe hemorrhage has evolved significantly in Norwegian medical emergency services in the last 10 years. Treatment algorithms for severe bleeding were previously focused on restoration of the blood volume by administration of crystalloids and colloids, but now the national trauma system guidelines recommend early balanced transfusion therapy according to remote damage control resuscitation principles. MATERIALS AND METHODS: This survey describes the implementation, utilization, and experience of the use of low titer group O whole blood (LTOWB) and blood components in air ambulance services in Norway. Medical directors from all air ambulance bases in Norway as well as the blood banks that support LTOWB were invited to participate. RESULTS: Medical directors from all 13 helicopter emergency medical services (HEMS) bases, the 7 search and rescue (SAR) helicopter bases, and the 4 blood banks that support HEMS with LTOWB responded to the survey. All HEMS and SAR helicopter services carry LTOWB or blood components. Four of 20 (20%) HEMS bases have implemented LTOWB. A majority of services (18/20, 90%) have a preference for LTOWB, primarily because LTOWB enables early balanced transfusion and has logistical benefits in time-critical emergencies and during prolonged evacuations. CONCLUSION: HEMS services and blood banks report favorable experiences in the implementation and utilization of LTOWB. Prehospital balanced blood transfusion using whole blood is feasible in Norway.

Risk of Harm Associated With Using Rapid Sequence Induction Intubation and Positive Pressure Ventilation in Patients With Hemorrhagic Shock.

Based on limited published evidence, physiological principles, clinical experience, and expertise, the author group has developed a consensus statement on the potential for iatrogenic harm with rapid sequence induction (RSI) intubation and positive-pressure ventilation (PPV) on patients in hemorrhagic shock. "In hemorrhagic shock, or any low flow (central hypovolemic) state, it should be noted that RSI and PPV are likely to cause iatrogenic harm by decreasing cardiac output." The use of RSI and PPV leads to an increased burden of shock due to a decreased cardiac output (CO)2 which is one of the primary determinants of oxygen delivery (DO2). The diminishing DO2 creates a state of systemic hypoxia, the severity of which will determine the magnitude of the shock (shock dose) and a growing deficit of oxygen, referred to as oxygen debt. Rapid accumulation of critical levels of oxygen debt results in coagulopathy and organ dysfunction and failure. Spontaneous respiration induced negative intrathoracic pressure (ITP) provides the pressure differential driving venous return. PPV subsequently increases ITP and thus right atrial pressure. The loss in pressure differential directly decreases CO and DO2 with a resultant increase in systemic hypoxia. If RSI and PPV are deemed necessary, prior or parallel resuscitation with blood products is required to mitigate post intervention reduction of DO2 and the potential for inducing cardiac arrest in the critically shocked patient.

A Pilot Trial of Platelets Stored Cold versus at Room Temperature for Complex Cardiothoracic Surgery.

BACKGROUND: This pilot trial focused on feasibility and safety to provide preliminary data to evaluate the hemostatic potential of cold-stored platelets (2° to 6°C) compared with standard room temperature-stored platelets (20° to 24°C) in adult patients undergoing complex cardiothoracic surgery. This study aimed to assess feasibility and to provide information for future pivotal trials. METHODS: A single center two-stage exploratory pilot study was performed on adult patients undergoing elective or semiurgent complex cardiothoracic surgery. In stage I, a two-armed randomized trial, platelets stored up to 7 days in the cold were compared with those stored at room temperature. In the subsequent single-arm stage II, cold storage time was extended to 8 to 14 days. The primary outcome was clinical effect measured by chest drain output. Secondary outcomes were platelet function measured by multiple electrode impedance aggregometry, total blood usage, immediate and long-term (28 days) adverse events, length of stay in intensive care, and mortality. RESULTS: In stage I, the median chest drain output was 720 ml (quartiles 485 to 1,170, n = 25) in patients transfused with room temperature-stored platelets and 645 ml (quartiles 460 to 800, n = 25) in patients transfused with cold-stored platelets. No significant difference was observed. The difference in medians between the room temperature- and cold-stored up to 7 days arm was 75 ml (95% CI, -220, 425). In stage II, the median chest drain output was 690 ml (500 to 1,880, n = 15). The difference in medians between the room temperature arm and the nonconcurrent cold-stored 8 to 14 days arm was 30 ml (95% CI, -1,040, 355). Platelet aggregation in vitro increased after transfusion in both the room temperature- and cold-stored platelet study arms. Total blood usage, number of adverse events, length of stay in intensive care, and mortality were comparable among patients receiving cold-stored and room temperature-stored platelets. CONCLUSIONS: This pilot trial supports the feasibility of platelets stored cold for up to 14 days and provides critical guidance for future pivotal trials in high-risk cardiothoracic bleeding patients.

Validation of a point-of-care capillary lactate measuring device (Lactate Pro 2).

BACKGROUND: The measurement of lactate in emergency medical services has the potential for earlier detection of shock and can be performed with a point-of-care handheld device. Validation of a point-of-care handheld device is required for prehospital implementation. AIM: The primary aim was to validate the accuracy of Lactate Pro 2 in healthy volunteers and in haemodynamically compromised intensive care patients. The secondary aim was to evaluate which sample site, fingertip or earlobe, is most accurate compared to arterial lactate. METHODS: Arterial, venous and capillary blood samples from fingertips and earlobes were collected from intensive care patients and healthy volunteers. Arterial and venous blood lactate samples were analysed on a stationary hospital blood gas analyser (ABL800 Flex) as the reference device and compared to the Lactate Pro 2. We used the Bland-Altman method to calculate the limits of agreement and used mixed effect models to compare instruments and sample sites. A total of 49 intensive care patients with elevated lactate and 11 healthy volunteers with elevated lactate were included. RESULTS: There was no significant difference in measured lactate between Lactate Pro 2 and the reference method using arterial blood in either the healthy volunteers or the intensive care patients. Capillary lactate measurement in the fingertip and earlobe of intensive care patients was 47% (95% CI (29 to 68%), p < 0.001) and 27% (95% CI (11 to 45%), p < 0.001) higher, respectively, than the corresponding arterial blood lactate. In the healthy volunteers, we found that capillary blood lactate in the fingertip was 14% higher than arterial blood lactate (95% CI (4 to 24%), p = 0.003) and no significant difference between capillary blood lactate in the earlobe and arterial blood lactate. CONCLUSION: Our results showed that the handheld Lactate Pro 2 had good agreement with the reference method using arterial blood in both intensive care patients and healthy volunteers. However, we found that the agreement was poorer using venous blood in both groups. Furthermore, the earlobe may be a better sample site than the fingertip in intensive care patients.

Cold-stored whole blood in a Norwegian emergency helicopter service: an observational study on storage conditions and product quality.

BACKGROUND: Increasing numbers of emergency medical service agencies and hospitals are developing the capability to administer blood products to patients with hemorrhagic shock. Cold-stored whole blood (WB) is the only single product available to prehospital providers who aim to deliver a balanced resuscitation strategy. However, there are no data on the safety and in vitro characteristics of prehospital stored WB. This study aimed to describe the effects on in vitro quality of storing WB at remote helicopter bases in thermal insulating containers. STUDY DESIGN AND METHODS: We conducted a two-armed single-center study. Twenty units (test) were stored in airtight thermal insulating containers, and 20 units (controls) were stored according to routine procedures in the Haukeland University Hospital Blood Bank. Storage conditions were continuously monitored during emergency medical services missions and throughout remote and blood bank storage. Hematologic and metabolic variables, viscoelastic properties, and platelet (PLT) aggregation were measured on Days 1, 8, 14, and 21. RESULTS: Storage conditions complied with the EU guidelines throughout remote and in-hospital storage for 21 days. There were no significant differences in PLT aggregation, viscoelastic properties, and hematology variables between the two groups. Minor significantly lower pH, glucose, and base excess and higher lactate were observed after storage in airtight containers. CONCLUSION: Forward cold storage of WB is safe and complies with EU standards. No difference is observed in hemostatic properties. Minor differences in metabolic variables may be related to the anaerobic conditions within the thermal box.

Trauma Hemostasis and Oxygenation Research Network position paper on the role of hypotensive resuscitation as part of remote damage control resuscitation.

The Trauma Hemostasis and Oxygenation Research (THOR) Network has developed a consensus statement on the role of permissive hypotension in remote damage control resuscitation (RDCR). A summary of the evidence on permissive hypotension follows the THOR Network position on the topic. In RDCR, the burden of time in the care of the patients suffering from noncompressible hemorrhage affects outcomes. Despite the lack of published evidence, and based on clinical experience and expertise, it is the THOR Network's opinion that the increase in prehospital time leads to an increased burden of shock, which poses a greater risk to the patient than the risk of rebleeding due to slightly increased blood pressure, especially when blood products are available as part of prehospital resuscitation.The THOR Network's consensus statement is, "In a casualty with life-threatening hemorrhage, shock should be reversed as soon as possible using a blood-based HR fluid. Whole blood is preferred to blood components. As a part of this HR, the initial systolic blood pressure target should be 100 mm Hg. In RDCR, it is vital for higher echelon care providers to receive a casualty with sufficient physiologic reserve to survive definitive surgical hemostasis and aggressive resuscitation. The combined use of blood-based resuscitation and limiting systolic blood pressure is believed to be effective in promoting hemostasis and reversing shock".

Immediate effects of blood donation on physical and cognitive performance-A randomized controlled double-blinded trial.

BACKGROUND: The success of implementing damage control resuscitation principles pre-hospital has been at the expense of several logistic burdens including the requirements for resupply, and the question of donor safety during the development of whole blood programs. Previous studies have reported effects on physical performance after blood donation; however, none have investigated the effects of blood donation on cognitive performance. METHOD: We describe a prospective double-blinded, randomized, controlled study comprised of a battery of tests: three cognitive tests, and VO2max testing on a cycle ergometer. Testing was performed 7 days before blinded donation (baseline day), immediately after donation (Day 0), and 7 days (Day 7) after donation. The inclusion criteria included being active blood donors at the Haukeland University Hospital blood bank, where eligibility requirements were met on the testing days, and providing informed consent. Participants were randomized to either the experimental (n = 26) or control group (n = 31). Control group participants underwent a 'mock donation" in which a phlebotomy needle was placed but blood was not withdrawn. RESULTS: In the experimental group, mean ± SEM VO2max declined 6% from 41.35 ± 1.7 mLO2/(min·kg) at baseline to 39.0 ± 1.6 mLO2/(min·kg) on Day 0 and increased to 40.51 ± 1.5 mLO2/(min·kg) on Day 7. Comparable values in the control group were 42.1 ± 1.8 mLO2/(min·kg) at baseline, 41.6 ± 1.8 mLO2/(min·kg)) on Day 1 (1% decline from baseline), and 41.8 ± 1.8 mLO2/(min·kg) on Day 7.Comparing scores of all three cognitive tests on Day 0 and Day 7 showed no significant differences (p > 0.05). CONCLUSION: Our main findings are that executive cognitive and physical performances were well maintained after whole blood donation in healthy blood donors. The findings inform postdonation guidance on when donors may be required to return to duty. LEVEL OF EVIDENCE: Randomized, controlled, double-blinded prospective trial study, level 1.

Emergency sternal intraosseous access for warm fresh whole blood transfusion in damage control resuscitation.

BACKGROUND: Intraosseous (IO) vascular access is increasingly used as an emergency tool for achieving access to the systemic circulation in critically ill patients. The role of IO transfusion of blood in damage control resuscitation is however questionable due to possible inadequate flow rate and hemolysis. Some experts claim that IO transfusion is contraindicated. In this study, we have challenged this statement by looking at flow rates of autologous fresh whole blood reinfusion and hemolysis using two of the commonly used Food and Drug Administration-approved and Conformité Européenne (CE)-marked sternal needles. Additionally, the success rate of sternal access between the two devices is evaluated. METHODS: Volunteer professional military personnel, were enrolled prospectively in a nonrandomized observational study design. We collected 450 mL of autologous whole blood from each participant. Participants were divided into the following three groups of 10: Tactically Advanced Lifesaving IO Needle (T.A.L.O.N.) IO, FAST1 IO, and intravenous group. The reinfusion was done by gravity only. Blood sampling was performed before blood collection and 30 minutes after reinfusion. Investigation of hemolysis was performed by measurements of haptoglobin and lactate dehydrogenase. Success rate was evaluated by correct aspiration of bone marrow. RESULTS: Median reinfusion rate was 46.2 mL/min in the FAST1 group, 32.4 mL/min in the T.A.L.O.N. group, and 74.1 mL/min in the intravenous group. Blood samples from all participants were within normal ranges. There was no statistically significant difference in haptoglobin and lactate dehydrogenase between the groups. In the FAST1 group, 1 (9%) of 11 procedures failed. In the T.A.L.O.N. group, 4 (29%) of 14 procedures failed. CONCLUSION: Although preferable, achieving peripheral venous access in the bleeding patient is a major problem. Our findings suggest that fresh whole-blood transfusion through the IO route is safe, reliable, and provide sufficient flow for resuscitation. LEVEL OF EVIDENCE: Therapeutic/Care management study, level III.

Airway and ventilation management strategies for hemorrhagic shock. To tube, or not to tube, that is the question!

Many standard trauma management guidelines advocate the early use of endotracheal intubation (ETI) and positive pressure ventilation as key treatment interventions in hemorrhagic shock. The evidence for using these airway and ventilation strategies to manage a circulation problem is unclear. The potentially harmful effects of drug-assisted intubation and positive pressure ventilation include reduced cardiac output, apnea, hypoxia, hypocapnea (due to inadvertent hyperventilation), and unnecessarily prolonged on-scene times. Conversely, the beneficial effects of spontaneous negative pressure ventilation on cardiac output are well described. Few studies, however, have attempted to explore the potential advantages of a strategy of delayed intubation and ventilation (together with a policy of aggressive volume replacement) in shocked trauma patients. Given the lack of evidence, the decision making around how, when, and where to subject shocked trauma patients to intubation and positive pressure ventilation remains complex. If providers choose to delay intubation, they must have the appropriate skills to safely manage the airway and recognize the need for subsequent intervention. If they decide to perform intubation and positive pressure ventilation, they must understand the potential risks and how best to minimize them. We suggest that for patients with hemorrhagic shock who do not have a compromised airway and who are able to maintain adequate oxygen saturation (or mentation if monitoring is unreliable), a strategy of delayed intubation should be strongly encouraged. LEVEL OF EVIDENCE: Review article, level IV.

Making whole blood available in austere medical environments: donor performance and safety.

BACKGROUND: To provide whole blood on the battlefield can be a challenge, but a buddy system protocol is both an elegant and the only currently available means to supply blood to a Special Forces team in far-forward locations. Our aim was to investigate donor-safety associated with such a protocol. METHODS: This study was a randomized, double-blinded, controlled trial that aimed to evaluate the immediate effects of a 450 cc blood donation on physical performance in fatigued and dehydrated Special Forces soldiers. The primary outcome variables were absolute and relative maximal oxygen uptake (VO2max ), exercise tolerance time (ETT) and heart rate (HR). RESULTS: Relative VO2max decreased by 7.1% in the donation group between pre and posttest, compared to no change in the control group. Absolute VO2max decreased by 11.2 and 3.6% between pre and posttest in the donation and control groups, respectively. Mean ETT in the donation group was on average 92 seconds shorter compared to baseline, which represents a decrease of 9.5%. CONCLUSION: Donating blood after a week of strenuous physical activity is feasible for Special Forces personnel. While the donation results in some diminishment of VO2max , a 3.6%-11.2% decrease in relative VO2max , and in elevation of submaximal HR levels highly trained personnel continue to perform well both at both sub-maximal and maximal effort levels.

"Blood failure" time to view blood as an organ: how oxygen debt contributes to blood failure and its implications for remote damage control resuscitation.

Hemorrhagic shock is both a local and systemic disorder. In the context of systemic effects, blood loss may lead to levels of reduced oxygen delivery (DO2 ) sufficient to cause tissue ischemia. Similar to other physiologic debts such as sleep, it is not possible to incur a significant oxygen debt and suffer no consequences for lack of timely repayment. While the linkage between oxygen debt and traditional organ failure (renal, hepatic, lung, and circulation) has been long recognized, we should consider failure in two additional linked and very dynamic organ systems, the endothelium and blood. These systems are very sensitive to oxygen debt and at risk for failing, having further implications on all other organ systems. The degree of damage to the endothelium is largely modulated by the degree of oxygen debt. Thus hypoperfusion is believed to begin a cascade of events leading to acute traumatic coagulopathy (ATC). This combination of oxygen debt driven endothelial damage and ATC might be considered collectively as "blood failure" due to the highly connected networks between these drivers. This article presents the implications of oxygen debt for remote damage control resuscitation strategies, such as permissive hypotension and hemostatic resuscitation. We review the impact of whole blood resuscitation and red blood cell efficacy in mitigation of oxygen debt. At last, this article recognizes the need for simple and durable, lightweight equipment that can detect the adequacy of tissue DO2 and thus patient needs for resuscitative care. Point-of-care lactate measuring may be a predictive tool for identifying high-risk trauma patients and occult shock because it provides information beyond that of vital signs and mechanism of injury as it may help predict the level of oxygen debt accumulation and need for resuscitation. Serial measurements may also be valuable as a tool in guiding resuscitative efforts.

Blood far forward: Time to get moving!

In planning for future contingencies, current problems often crowd out historical perspective and planners often turn to technological solutions to bridge gaps between desired outcomes and the reality of recent experience. The US Military, North Atlantic Treaty Organization, and other allies are collectively taking stock of 10-plus years of medical discovery and rediscovery of combat casualty care after the wars in Iraq and Afghanistan. There has been undeniable progress in the treatment of combat wounded during the course of the conflicts in Southwest Asia, but continued efforts are required to improve hemorrhage control and provide effective prehospital resuscitation that treats both coagulopathy and shock. This article presents an appraisal of the recent evolution in medical practice in historical context and suggests how further gains in far forward resuscitation might be achieved using existing technology and methods based on whole-blood transfusion while research on new approaches continues.

The lost art of whole blood transfusion in austere environments.

The optimal resuscitation fluid for uncontrolled bleeding and hemorrhagic shock in both pre- and in-hospital settings has been an ongoing controversy for decades. Hemorrhage continues to be a major cause of death in both the civilian and military trauma population, and survival depends on adequacy of hemorrhage control and resuscitation between onset of bleeding and arrival at a medical treatment facility. The terms far-forward and austere are defined, respectively, as the environment where professional health care providers normally do not operate and a setting in which basic equipment and capabilities necessary for resuscitation are often not available. The relative austerity of a treatment setting may be a function of timing rather than just location, as life-saving interventions must be performed quickly before hemorrhagic shock becomes irreversible. Fresh whole blood transfusions in the field may be a feasible life-saving procedure when facing significant hemorrhage.