SCIENTIFIC
The First Prehospital Administration of Whole Blood in West Virginia for Atraumatic Hemorrhage
AUTHORS: Sahil Dayal, MD
D. Scott Jobe, DO James Scheidler, MD
AFFILIATIONS: Department of Emergency Medicine
West Virginia University School of Medicine
CORRESPONDING AUTHOR:
Sahil Dayal, MD sahil. dayal @ wvumedicine. org
DISCLOSURES: None
ETHICS STATEMENT:
Permission from the patient has been obtained.
FUNDING: None
CASE PRESENTATION
A 50-year-old man with a past medical history of alcohol use disorder, complicated withdrawal, tobacco use disorder, and hypertension experienced worsening abdominal pain, nausea, and hematemesis. After approximately 17 hours after the start of the symptoms, emergency medical services( EMS) was called via 911 as family noted increased bloody vomitus. Harrison County Emergency Squad( HCES) responded emergently.
Upon first patient contact, advanced life support( ALS) providers noted coffee ground emesis filling the patient’ s toilet bowl and large volume frank hematemesis. The patient was noted to be diaphoretic, cool, and pale with blood pressure( BP) of 60 / 40 and heart rate( HR) of 125. The initial Glasgow coma scale( GCS) score was 15, end-tidal CO2( ETCO2) was 15, and the shock index( SI) was 2.1. ETCO2, a measure
ABSTRACT
This case highlights the first prehospital whole blood administration in a nontraumatic case of hemorrhagic shock as delivered by a 911 Emergency Medical Services( EMS) system in the state of West Virginia. EMS was called to the home of a 50-yearold man with a gastrointestinal bleed. The patient’ s Glasgow coma scale( GCS) score declined from 15 to 9 shortly after contact.
of carbon-dioxide exhaled during respirations, provides real-time data detailing the efficacy of patients’ perfusion, ventilation, and metabolic state. SI, defined as a HR divided by systolic BP, has been used to predict increased risk of morbidity, mortality, and mass transfusion with values > 1.0 indicating significantly higher risk. Normal SI is defined as < 0.5-0.7, with increasing risk of mortality as the number rises. At this time, the ALS crew on scene requested the response of the on-duty paramedic supervisor certified to carry and administer whole blood. An 18-gauge peripheral intravenous line was secured. While obtaining IV access, the patient’ s GCS score declined precipitously from 15 to 9 and he became more pale, diaphoretic, and weak, indicating further evidence of hemorrhagic shock. Upon arrival, the certified blood medic initiated the transfusion of 500 mL( 1 unit) of low titer O whole blood( LTOWB) in a pressure bag using the Warrior Lite blood warmer while enroute to the nearest emergency department( ED). The patient’ s condition improved after transfusion showing improvement in GCS from 9 to 15, HR from 132 to 109, and ETCO2 from 15 to 25. BP remained low at 80 / palpation although his SI had improved from 2.1 to 1.4.
On arrival to the ED, he received intravenously( IV) one unit of packed red blood cells, one liter of normal saline, ceftriaxone, octreotide, and pantoprazole. Central venous access was also obtained. Vital signs were responsive to blood and IV fluids as follows: BP 102 / 71, HR 100, and respiratory rate( RR) 20, with pulse oximetry reading
Due to the decline, EMS transfused one unit of low titer O-negative whole blood en route to the nearest emergency department. His GCS score improved to 15, shock index lowered from 2.1 to 1.4, and pallor and diaphoresis improved. Ultimately, the patient was able to ambulate out of the hospital independently after being stabilized and treated further in the hospital setting.
of 96 % on room air. Additionally, he was found to have lactic acidosis of 4.0, acute kidney injury( AKI) with serum creatinine of 3.67 and blood urea nitrogen( BUN) of 94 highly indicative of upper gastrointestinal( GI) bleeding. Gastroenterology was consulted and recommended emergent esophagogastroduodenoscopy( EGD).
The patient was admitted to the hospitalist service pending EGD but left against medical advice on the day of admission. At the time of discharge, the patient was noted to have full decision-making capacity and left under his own power against medical advice( AMA). Medical contact was made with the patient approximately 10 months after transfusion and was well and able to provide his consent for this publication.
DISCUSSION
This case report describes the first prehospital LTOWB transfusion for nontraumatic hemorrhage by a ground ALS service in WV and represents a historic landmark for the state’ s EMS system. HCES is one of four EMS transport agencies in Harrison County. Collectively it serves a population of approximately 70,000 individuals in over 450 square miles, including those patients covered by mutual aid agreements. HCES responds to approximately 11,000 calls for service each year. LTOWB was first added to 911 units from Cabell County EMS( CCEMS) in Cabell County, WV, as part of a pilot program that started in November 2023; HCES joined the pilot program and started carrying LTOWB in March 2024. The WV Office of Emergency Medical
West Virginia Medical Journal • December 2025 • 21