Transfusion of Stored Whole Blood in a Civilian Trauma Center: A Prospective Evaluation of Feasibility and Outcomes
Conditions: Trauma, Hemorrhage, Coagulopathy
Sponsor: University of California, Los Angeles

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Henry Gill Cryer, MD, PhD 
Clinical Research Protocol 
TRANSFUSION OF WHOLE BLOOD IN A CIVILIAN TRAUMA CENTER: A 
PROSPECTIVE EVALUATION OF FEASIBILITY AND OUTCOMES 
Version Date: 
04/17/2017 
Investigational Product: 
Cold stored whole blood 
IND Number: 
exempt 
Development Phase: 
Phase 2 
Sponsor/Investigator: 
Henry Gill Cryer, MD, PhD 
757 Westwood Plaza Suite 8501 
Los Angeles, CA 90095 
Funding Organization: 
National Trauma Institute 
Principal Investigator: 
Name:  
Henry Gill Cryer, MD, PhD 
Telephone: 
(310) 267-9594 
E-mail: hcryer@mednet.ucla.edu 
 
Medical Monitor: 
Name:  
William Mower, MD 
Telephone: 
(310) 825-2111 
E-mail: 
wmower@mednet.ucla.edu 
Coordinating Center: 
n/a 
 
 
 
 
 

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Protocol Title:  TRANSFUSION OF WHOLE BLOOD IN A CIVILIAN TRAUMA 
CENTER: A PROSPECTIVE EVALUATION OF FEASIBILITY AND OUTCOMES  
 
Protocol Date:  December 5, 2016, revised April 17, 2017 
 
 
 

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Table of Contents 
1 BACKGROUND ........................................................................................................ 12 
1.1 Overview of Non-Clinical Studies ....................................................................... 13 
1.2 Overview of Clinical Studies ............................................................................... 14 
2 STUDY RATIONALE ............................................................................................... 17 
2.1 Risk / Benefit Assessment ................................................................................... 17 
3 STUDY OBJECTIVES ............................................................................................... 18 
3.1 Primary Objective ................................................................................................ 18 
3.2 Secondary Objectives........................................................................................... 18 
4 STUDY DESIGN........................................................................................................ 18 
4.1 Study Overview ................................................................................................... 18 
5 CRITERIA FOR EVALUATION .............................................................................. 19 
5.1 Primary Efficacy Endpoint .................................................................................. 19 
5.2 Safety Evaluations ............................................................................................... 20 
6 PATIENT SELECTION ............................................................................................. 21 
6.1 Study Population .................................................................................................. 21 
6.2 Inclusion Criteria ................................................................................................. 23 
6.3 Exclusion Criteria ................................................................................................ 23 
7 CONCURRENT MEDICATIONS ............................................................................. 23 
7.1 Allowed Medications and Treatments ................................................................. 23 
8 STUDY TREATMENTS ............................................................................................ 23 
8.1 Method of Assigning Patients to Treatment Groups............................................ 23 
8.2 Blinding................................................................................................................ 24 
8.3 Formulation of Test and Control Products........................................................... 24 
8.3.1 Packaging and Labeling ................................................................................ 24 
8.4 Supply of Study Drug at the Site ......................................................................... 24 
8.4.1 Dosage/Dosage Regimen .............................................................................. 25 
8.4.2 Dispensing..................................................................................................... 25 

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8.4.3 Administration Instructions .......................................................................... 25 
8.4.4 Storage .......................................................................................................... 25 
8.5 Study Drug Accountability .................................................................................. 25 
9 STUDY PROCEDURES AND GUIDELINES .......................................................... 25 
9.1 Clinical Assessments ........................................................................................... 26 
9.1.1 Concomitant Medications ............................................................................. 26 
9.1.2 Demographics ............................................................................................... 26 
9.1.3 Medical History ............................................................................................ 26 
9.1.4 Vital Signs ..................................................................................................... 26 
9.1.5 Oximetry ....................................................................................................... 26 
9.1.6 Other Clinical Procedures ............................................................................. 26 
9.1.7 Adverse Events ............................................................................................. 27 
9.2 Clinical Laboratory Measurements ...................................................................... 27 
9.2.1 Hematology ................................................................................................... 27 
9.2.2 Blood Chemistry Profile ............................................................................... 27 
9.2.3 Pregnancy Test .............................................................................................. 27 
9.3 Research Laboratory Measurements .................................................................... 27 
9.3.1 Thromboelastography (TEG)/platelet mapping ................................................ 27 
10 EVALUATIONS BY VISIT..................................................................................... 28 
10.1 Visit 1 (Days 1-365)........................................................................................... 28 
11 ADVERSE EXPERIENCE REPORTING AND DOCUMENTATION ................. 31 
11.1 Adverse Events .................................................................................................. 31 
11.2 Serious Adverse Experiences (SAE) ................................................................. 33 
11.2.1 Serious Adverse Experience Reporting ...................................................... 34 
11.3 Protocol Defined Important Medical Findings Requiring Real Time Reporting
 
34 
11.4 Medical Monitoring ........................................................................................... 34 
12 DISCONTINUATION AND REPLACEMENT OF PATIENTS ............................ 34 

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12.1 Early Discontinuation of Study Drug ................................................................ 34 
12.3 Withdrawal of Patients from the Study .............................................................. 35 
12.4 Replacement of Patients ..................................................................................... 35 
12.5 Stopping Criteria ................................................................................................ 35 
13 PROTOCOL VIOLATIONS .................................................................................... 36 
14 DATA SAFETY MONITORING............................................................................. 36 
15 STATISTICAL METHODS AND CONSIDERATIONS........................................ 36 
15.1 Data Sets Analyzed ............................................................................................ 36 
15.3 Analysis of Primary Endpoint ............................................................................ 37 
15.4 Analysis of Secondary Endpoints ...................................................................... 37 
15.5 Interim Analysis ................................................................................................. 38 
16 DATA COLLECTION, RETENTION AND MONITORING ................................ 39 
16.1 Data Collection Instruments .............................................................................. 39 
16.2 Data Management Procedures ........................................................................... 39 
16.3 Data Quality Control and Reporting .................................................................. 39 
16.4 Archival of Data ................................................................................................. 39 
16.5 Availability and Retention of Investigational Records ...................................... 40 
16.6 Monitoring ......................................................................................................... 40 
16.7 Patient Confidentiality ....................................................................................... 40 
17 ADMINISTRATIVE, ETHICAL, REGULATORY CONSIDERATIONS ............ 40 
17.1 Protocol Amendments ........................................................................................ 40 
17.2 Institutional Review Board ................................................................................ 41 
17.3 Waiver of Informed Consent ............................................................................. 41 
18 PUBLICATIONS .................................................................................................. 42 
19 Investigator Responsibilities ................................................................................. 42 
20 Appendix I: Schedule of Events ........................................................................... 43 
21 REFERENCES ..................................................................................................... 44 
 

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LIST OF ABBREVIATIONS 
 
AABB 
American Association of Blood Banks 
AE 
adverse event 
ALT 
alanine aminotransferase 
ARDS 
acute respiratory distress syndrome 
AST 
aspartate aminotransferase 
BUN 
blood urea nitrogen 
CAT 
Calibrated Automated Thromboelastogram 
CFR 
Code of Federal Regulations 
CRF 
case report form 
FWB 
Fresh whole blood 
FDA 
GCS 
Food and Drug Administration 
Glasgow coma scale 
HIPAA 
Health Insurance Portability and Accountability Act of 1996 
IRB 
Institutional Review Board 
IV 
intravenous 
MA 
Maximum amplitude 
mL 
milliliter 
OHRPP 
Office of Human Research Protection Program 
PI 
Principal Investigator 
PPE 
Personal Protective Equipment 
PRBC 
Packed Red Blood Cells 
R 
RBC 
Reaction time 
Red blood cell 
SAE 
serious adverse event 
TACO 
TBSA 
Transfusion-associated circulatory overload 
Total body surface area 
TEG 
thromboelastography 
TRALI 
Transfusion-associated lung injury 
UCLA 
University of California Los Angeles 
WB 
Whole blood 
 
 

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PROTOCOL SYNOPSIS 
TITLE 
 
TRANSFUSION OF WHOLE BLOOD IN A CIVILIAN 
TRAUMA CENTER: A PROSPECTIVE EVALUATION OF 
FEASIBILITY AND OUTCOMES  
 
 
 
SPONSOR/INVESTIG
ATOR 
Henry Magill Cryer, MD, PhD 
 
 
FUNDING 
ORGANIZATION 
National Trauma Institute (Department of Defense/Army Medical 
Research Acquisition Activity) 
 
NUMBER OF SITES 
1 
 
 
RATIONALE 
Our study will test the feasibility of providing whole blood (WB) for 
resuscitation of adult male trauma patients in hemorrhagic shock and 
determine the effects of WB on clinical outcomes as well as the 
effects on coagulation, fibrinolysis, and inflammation, and hemolytic 
transfusion reactions compared to standard blood component therapy.  
 
 
 
STUDY DESIGN 
Prospective cohort study 
 
 
PRIMARY 
OBJECTIVE 
1. 
Compare volume of blood transfusion within 24 hours of 
admission between patients receiving whole blood and standard 
component therapy.  
 
 
SECONDARY 
OBJECTIVES 
The study will also compare: 
1. 
Functional coagulopathy as measured by thromboelastography; 

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2. 
30-day mortality;  
3. 
Number of units of blood products transfused by 
component/product;  
4. 
Complications; 
5. 
Hemolysis; 
6. 
Wastage of blood units. 
 
 
NUMBER OF 
PATIENTS 
Whole blood arm - 49 male patients over apparent age 18. 
Component therapy arm –49 male and female patients over apparent 
age 18.  
 
 
PATIENT 
SELECTION 
CRITERIA 
Inclusion Criteria:  
 Whole blood arm: Male trauma patients over apparent age 18 
with massive transfusion activation and presenting systolic 
blood pressure <100, who are receiving or will receive whole 
blood for initial resuscitation 
 Component therapy arm: Male and female trauma patients 
over apparent age 18 with massive transfusion activation and 
presenting systolic blood pressure <100, who have received, 
are receiving or will receive component therapy for initial 
resuscitation. 
Exclusion Criteria: 
 Patients with burns over >20% total body surface area 
 
 
TEST PRODUCT, 
DOSE, AND ROUTE 
OF 
ADMINISTRATION 
Group O+ whole blood stored at 1-6 °C for up to 10 days.  Patients 
may receive up to 4 units during the initial phase of the proposed 
study, to be increased to up to 6 units (see 5.2 Safety Evaluations) 
Product is administered to replace ongoing blood loss and 
restore/maintain hemodynamic stability and hemostasis.  Product will 
be transfused intravenously as needed during initial traumatic 
resuscitation only.  Following administration of whole blood if further 
transfusion is needed during initial trauma resuscitation, or after 
resuscitation is completed, the patient will receive standard 

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component therapy (packed red blood cells, plasma and platelets in a 
1:1:1 ratio). 
 
 
 
 
 
CONTROL 
PRODUCT, DOSE 
AND ROUTE OF 
ADMINISTRATION 
Component therapy consisting of packed red blood cells, thawed fresh 
frozen plasma and platelets in a 1:1:1 ratio.  Product will be 
transfused intravenously as needed to replace ongoing blood loss and 
restore/maintain hemodynamic stability and hemostasis. 
 
 
 
DURATION OF 
PATIENT 
PARTICIPATION 
AND DURATION OF 
STUDY 
Patient participation includes up to 24 hours of transfusion, up to 5 
days of laboratory testing, and up to one year of follow up by chart 
review.  Follow up by chart review will continue throughout the 
patient’s hospital stay or up to one year, whichever is shorter.  Most 
hospital stays are anticipated to be approximately 14 days.   
Screening:  not applicable 
Treatment:  1 day / 24 hours.  Patients will receive whole blood 
only during initial resuscitation for traumatic hemorrhage, which is 
generally complete within a few hours.  
Follow-up:   
5 days (laboratory testing) + chart review for up to 1 year if the 
patient remains in the hospital 
The total duration of study enrollment and completion of follow up is 
expected to be two years.  
 
 
CONCOMMITANT 
MEDICATIONS 
Allowed: all 
 
Prohibited: none 
 
 

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EFFICACY 
EVALUATIONS: 
 
PRIMARY ENDPOINT 
1. Primary analysis will compare volume of blood transfusion within 
24 hours of admission for patients with traumatic hemorrhagic 
shock without severe TBI (GCS ≤8 and evidence of brain injury 
on imaging) who have received WB versus component therapy 
for initial resuscitation.  
SECONDARY 
ENDPOINTS 
1. Volume of blood transfusion within 24 hours of admission for 
patients with severe TBI (GCS ≤8 and evidence of brain injury 
on imaging) and for entire cohort of patients. 
2. Thromboelastography parameters including maximum 
amplitude, reaction time, alpha angle, fibrinolysis, and platelet 
function at 3 and 6 hours of resuscitation, after every 6 units of 
whole blood equivalent (WB or PRBCs), at the time of 
completion of resuscitation (time of last unit of blood product 
given), and on ICU days 1, 3 and 5.  
3. 30-day mortality;  
4. Duration of need for renal replacement therapy, mechanical 
ventilation, ICU admission, and hospital stay;  
5. Number of units of blood products transfused by 
component/product during first 24 hours of admission and 
total for hospitalization;  
6. Complications which include 30-day mortality, clinical 
coagulopathy, infection, venous thromboembolism, 
cerebrovascular accident, acute coronary syndrome, 
transfusion-related lung injury, transfusion-associated cardiac 
overload; 
7. Hemolysis as measured by haptoglobin, bilirubin, lactate 
dehydrogenase, and direct antiglobulin 
8. Wastage of blood units 
SAFETY 
EVALUATIONS 
Complications which include death, clinical coagulopathy, infection, 
venous thromboembolism, cerebrovascular accident, acute coronary 
syndrome, transfusion-related lung injury, transfusion-associated 
cardiac overload; 
Hemolysis as measured by haptoglobin, bilirubin, lactate 

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dehydrogenase, and direct antiglobulin. 
PLANNED INTERIM 
ANALYSES  
When approximately 50% of patients have been enrolled in the study, 
an interim analysis for safety will be conducted by the statistician and 
independent medical monitor. Serious adverse events will be 
monitored by the medical monitor on an ongoing basis throughout the 
study. 
 
 
STATISTICS 
Primary Analysis Plan 
For continuous variables including the primary endpoint (volume of 
blood products transfused during the first 24 hours of admission), the 
statistical method will depend on the distribution of the data.  If the 
data appears to follow a normal distribution, a t-test will be used, 
otherwise, a nonparametric Wilcoxian rank sum test will be used.   
To analyze coagulopathy over time a mixed effects linear regression 
model will be used.  
A mixed effects linear regression model will also be used to adjust for 
confounding variables  such as sex, age, comorbidities, severity of 
injury, and physiologic parameters of shock including pH and 
temperature , and use of a rapid transfuser (which more effectively 
warms blood).   
Rationale for Number 
of Patients 
A sample size of 49 whole blood group (study drug) and 49 
component therapy group (control) patients (98 patients total) is 
estimated.  18 of these per group are expected to have severe TBI and 
will be excluded from primary analysis, leaving 31 patients per group 
for the primary analysis. Using a Type I error rate of 0.05, and effect 
size based on reduction of PRBC and plasma transfusions described 
in the sensitivity analysis in a study by Cotton et al, 31 patients per 
group is expected to have 80% power to detect a significant difference 
in volume of transfusion in 24 hours. 1 
 
 
 

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1 
BACKGROUND 
 
Massive hemorrhage is a major cause of potentially preventable death following 
trauma. 2-6 A common consequence of hemorrhagic shock is uncontrollable bleeding 
from coagulopathy, leading to death from exsanguination. Even when bleeding is 
controlled, patients are at increased risk of complications and mortality. 7,8 Reconstituted 
whole blood, or component therapy with PRBCs, plasma, and platelets was introduced by 
the military in recent conflicts in Iraq and Afghanistan with remarkable results and has 
been adopted by most civilian trauma centers.  9 Despite improving coagulopathy, it is 
apparent that transfusion of blood components is not equivalent to whole blood 
transfusion. 10-12  Transfusion of high plasma volumes may be associated with increased 
risk of allergic reaction, transfusion associated acute lung injury (TRALI), hypervolemic 
cardiac failure/transfusion-associated circulatory overload (TACO), and ARDS. 13 
 
Military services that have recently reintroduced fresh whole blood (FWB) for 
standard resuscitation of massive hemorrhage have found that FWB offers a survival 
advantage over component therapy, and that risks of transfusion reactions are similar for 
FWB and component therapy with PRBCs. 6 On the civilian side, whole blood is an 
FDA-licensed product that has been in use in pediatric open heart surgery and autologous 
transfusion but is no longer commonly available for other indications.  However, the 
military results are renewing interest in whole blood for trauma resuscitation. The use of 
low-titer (anti-A/anti-B) group O-positive whole blood that is leukoreduced with a 
platelet-sparing filter was recently approved by the UCLA Blood and Blood Derivatives 
Committee (Transfusion Committee) for male trauma patients.  
 
To provide effective treatment for traumatic hemorrhage, blood product 
transfusion must provide the oxygen-carrying capacity provided by red blood cells and 
the hemostatic capacity provided by platelets and clotting factors.  Whole blood offers the 
advantages of more precisely approximating shed blood; decreased volume of additives 
per transfusion episode; and exposure to a decreased number of donors for a patient 
undergoing massive transfusion. As described below, the military experience, initial 
civilian studies, and preclinical studies indicate that whole blood may be superior to 
component therapy particularly with regard to hemostatic capacity, though it remains to 
be seen whether this will translate into differences in coagulopathy, inflammation, 
transfusion requirements, and mortality.  Additional considerations include optimal 
storage conditions that maintain the function of red cells, platelets, and clotting factors; as 
well as careful consideration and mitigation of the risk of transfusion reaction when the 
group O plasma in whole blood units is administered to non-group O recipients. Evidence 
of the safety of this product is provided in the following sections.  
 
 

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1.1 
Overview of Non-Clinical Studies 
 
Laboratory studies indicate that cold-stored whole blood retains hemostatic ability 
over at least 10 days at 2-6°C, and likely longer.  Spinella et al 14 and Pidkoke et al 15 
have extensively reviewed the hemostatic capacity of cold-stored WB and the viability of 
platelets in this product.  In those reviews, there is convincing evidence that cold-stored 
platelets not only retain function but that they perform better than room temperature-
stored platelets in aggregation studies. Most of the studies in these reviews evaluated 
storage up 7 days. However, several studies have specifically addressed platelet function 
in WB stored for 21 days or longer with similar findings.  Jobes et al demonstrated that in 
unfiltered WB stored at 1-6°C, platelet counts decrease starting at day 4 and then level off 
and stabilize by day 7.16  Additionally, platelet function in cold stored WB as measured 
by platelet aggregometry showed no change in in the aggregation responses to ADP and 
epinephrine stimulation from day 1 to day 21 of storage but did have a decline in 
response to collagen by day 7 and ristocetin by day 17. However, despite a gradual 
decline in platelet count and response to some agonists, global platelet function in the 
stored unit as measured by thromboelastography (TEG) was maintained within the 
normal range until day 14 of storage 16.  
 
Pidkoke et al. found similar results showing that refrigerated (1-6°C) WB 
improved impedance platelet aggregation and TEG results compared to WB units stored 
at 22°C for 21 days. In this study, prolongation of prothrombin time was also attenuated 
by refrigeration. 17 Functional clotting capacity as measured by thromboelastography 
remained relatively stable in refrigerated units over 21 days.  In studies performed at 
UCLA, we found similar results with TEG values maintained within the normal range for 
up to 35 days of storage at 1-6°C in unfiltered WB (manuscript accepted, Journal of 
Trauma and Acute Care Surgery).   
 
Standard leukoreduction techniques for blood processing remove platelets as well 
as white blood cells. Our study proposes to use a platelet-sparing leukoreduction filter 
which has previously been evaluated for leukoreduction of whole blood (Imuflex WB-SP, 
Terumo). 18.  The filter works with a polyurethane membrane that permits passage of 
RBCs and platelets but impedes white blood cells.  Theoretically passage through the 
filter could activate RBCs and platelets and target them for destruction, but this was not 
the case based on in vivo recovery of radiolabeled red cells and platelets after autologous 
transfusion. PRBCs, platelets, and plasma produced by the filter were tested to and 
confirmed to meet FDA requirements, including leukoreduction standards. 18  

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Additionally, Strandenes et al. recently demonstrated that global platelet function as 
measured by ROTEM is maintained in WB that has been stored at 2-6°C for up to 21 
days after filtration with this platelet-sparing filter. In that study, maximum clot firmness 
began to decrease by day 10-14 but remained within the reference range through day 21.  
19  These data provide convincing evidence that platelet function in a 10-day-old unit of 
filtered WB will be adequate to support hemostasis.  
 
Optimal storage conditions for refrigerated whole blood have also been 
investigated.  Using the platelet-sparing filter, Yazer et al studied whether whole blood 
should be agitated to enhance platelet function, or whether this would damage the red 
cells. 20  In this study, whole blood was maintained between 20-24°C  before 
leukoreduction occurred within 8 hours; blood was then immediately placed in a 1-6°C 
refrigerator. Units then underwent infectious disease testing over 3 days, and were then 
delivered to the transfusion service.  This timeline and storage plan is the same as that 
used in the proposed study.  After processing, units were stored for 21 days under 
different rocking conditions.  Based on thromboelastography and markers of hemolysis, 
the recommended storage condition for cold stored whole blood is stationary for up to 10 
days. Importantly, platelet function did not appear to be affected by either leukoreduction 
or cold storage.  
 
Platelets were routinely stored at 4°C until the 1980s, and appeared to be safe 
during this time. These storage conditions were phased out because of the decreased 
circulation time of cold-stored platelets compared to platelets stored at room temperature, 
in order to best serve patients requiring prophylactic transfusions. 21 It was assumed, but 
not proven, that these would be as effective as cold-stored platelets for actively 
hemorrhaging patients. Taken together, the above evidence indicates that in actively 
bleeding patients, cold-stored platelets are likely to achieve faster hemostasis than room 
temperature-stored platelets, and are more likely to prevent re-bleeding in patients 
requiring high mean arterial pressure, such as spinal cord injury patients. 
1.2 
Overview of Clinical Studies 
 
The change in standard practice from whole blood transfusion, to fractionation 
and component transfusion, occurred after the 1970s because of concerns over resource 
utilization and safety. However, there was no evidence documenting equivalence between 
whole blood and components for trauma patients, and new data is now suggesting that 
whole blood may be superior for obtaining hemostasis and oxygen delivery for the 
acutely bleeding trauma patient.  22   
 
The first evidence that whole blood may be superior to component therapy for 
trauma patients comes from military studies in Iraq and Afghanistan using fresh whole 
blood (FWB).  FWB was initially used as a source of platelets, in addition to PRBCs and 

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plasma, when platelets were not available in far-forward military settings. 23 A 
retrospective analysis of prospectively collected data from all transfused patients at 6 
forward surgical teams comparing standard component therapy to component therapy 
with whole blood substituted for platelets found that when adjusted for confounding 
variables, patients who received FWB had a significant survival advantage. 23 Of note, a 
subgroup analysis of patients who received “universal-donor” group O FWB (49%) 
versus type-specific product found there was no difference in mortality between these 
groups, and that there were no transfusion reactions.  
 
Similarly, a retrospective analysis of 354 combat casualties transfused at least one 
unit of PRBCs compared standard component therapy with PRBCs, plasma, and warm 
FWB.  24  Patients who received whole blood had significantly lower transfusion volume 
requirements, and received significantly less preservative and anticoagulant additive 
volume, compared to patients receiving standard component therapy. 24 hour and 30 day 
survival was significantly higher in the whole blood group.  
 
On the civilian side, a recent randomized controlled pilot trial compared whole 
blood leukoreduced with a non-platelet-sparing filter and stored for up to 5 days at 1-6°C, 
supplemented with warm stored platelets, to regular component therapy in severely 
injured patients predicted to require large volume transfusion.  1  There was a trend 
towards decreased plasma and platelet requirements in the whole blood group in the on-
protocol analysis. In post hoc analysis use of whole blood was associated with a 
reduction in the amount of transfusion when traumatic brain injury was excluded.    
 
Current FDA regulations stipulate that whole blood must be type-specific.  
However, as reviewed by Spinella et al (7) and Berseus et al 25, there is convincing 
evidence that the risk of a hemolytic transfusion reaction from transfusion of low titer 
group O WB is minimal. As these authors point out, the US Army used low titer group O 
WB as a universal donor blood in the Vietnam conflict. Per their report, there was only 
one reported hemolytic transfusion reaction from transfusion of group O WB where a 
group A patient incorrectly received a unit that was labeled high titer. There were no 
reported hemolytic transfusion reactions following transfusion of low titer group O WB 
to non-group O patients. Berseus et al have reviewed the known literature on hemolytic 
transfusion reactions after transfusion of group O products to non-group O recipients and 
found that virtually no such reactions occur in association with low titer O products.  25 
The authors concluded that “there is an overwhelming experience, particularly from the 
transfusion of low titer universal group O whole blood in the military service, showing 
that the frequency of severe hemolytic transfusion reactions is nearly negligible”. 25  
Finally, Yazer et al have shown that it is safe to initiate resuscitation from hemorrhagic 
shock in male patients with low titer group O+ WB in a civilian trauma center.  In this 
study, patients were transfused up to 2 units uncrossmatched group O positive WB 

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leukoreduced using a platelet-sparing filter and stored at 1-6°C for up to 10 days for male 
trauma patients with hypotension due to hemorrhage.   Outcomes were compared to 
historical controls.  No adverse reactions and no laboratory evidence of increased 
hemolysis in the whole blood group was found.26 That institution has now increased their 
initial transfusion of low titer group O+ WB to 4 units with similar results (personal 
communication).  Our study seeks to build on this work by establishing efficacy of cold 
stored whole blood leukoreduced with a platelet sparing filter. Only low anti-A, anti-B 
group O-positive whole blood will be used as a universal donor in the proposed study. 
Platelets, which are not typically crossmatched, have occasionally resulted in hemolytic 
reactions after transfusion.  In the 25 publications reviewed, all but one reaction resulted 
from a unit with a titer of >1:100 (saline) or >1:400 (antiglobulin); often, titers were 
>1:1000. Our study proposes to use a cutoff of <1:100. 
 
There have been reports of hemolytic reactions when a patient initially transfused 
with unmatched group O whole blood later received type-specific transfusion.   A similar 
situation is encountered in current massive transfusion protocols and hemolytic reactions 
are prevented using the following precautions. Currently when the patient’s blood type is 
unknown during a massive transfusion activation at UCLA, sets of 6 group O PRBC 
units, 6 pre-thawed group A plasma units and 1 apheresis platelet unit are provided.  
Once the blood type of the patient is determined, the blood bank switches to providing 
type-specific products unless the patient’s blood type is group B or AB (i.e. incompatible 
with the group A plasma); under this circumstance, the blood bank provides another set 
of 6 group O PRBC units and compatible plasma before switching to type specific 
PRBCs. We have not identified any hemolytic transfusion reactions using this approach.  
We intend to follow this same practice with the transfusion of low titer group O+ WB. If 
after receiving low titer group O+ WB the patient’s blood type is found to be a type other 
than group O, the blood bank will provide a set of group O PRBC units and compatible 
plasma units, before switching to type specific PRBC units. 
 
Providing further evidence of the safety of this approach, our institution 
participated in a multi-center study evaluating the safety of the use of thawed group A 
plasma in trauma patients. 27 This study evaluated trauma patients that received group A 
plasma as part of the initial resuscitation (354 B and AB patients and 809 A patients). 
The two study groups were comparable in terms of age, gender, TRISS probability of 
survival, and total number of blood products transfused. The study found that the use of 
group A thawed plasma during the initial resuscitation of injured patients of unknown 
ABO group was not associated with increased in-hospital mortality, early mortality or 
hospital length of stay for group B and AB patients compared to group A patients. 
Additionally, of the 17 participating centers, only 4 (24%) provide low-titer group A 
plasma; the other 13 centers do not perform titers of the plasma components. This 

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experience indicates that transfusion of group A thawed plasma, regardless of anti-B titer, 
is safe. A manuscript reporting these findings was recently accepted by Transfusion 
(accepted March 15, 2017).   
  
 
2 
STUDY RATIONALE 
The evidence described above indicates that low titer group O cold-stored whole blood 
stored for up to 10 days may be a superior product for obtaining hemostasis and 
maintaining oxygen delivery in hemorrhaging trauma patients in the emergent setting, 
compared with component therapy.  A prior study has demonstrated the safety of this 
universal donor product in adult male civilian trauma patients 28; however, efficacy must 
be determined in a prospective civilian context.   
The advantage of cold-stored whole blood may be due to several factors, or a 
combination of factors, including superior platelet function, lack of storage lesion, and 
decreased volume of preservative and anticoagulant additives.  These factors will be 
evaluated in our study.   
2.1 
Risk / Benefit Assessment 
As described above (See sections 1.1 and 1.2, Overview of Non-Clinical and Clinical 
Studies), low titer group O cold-stored whole blood stored for up to 10 days has been 
shown to be safe as a universal donor product. There is substantial evidence from 
literature spanning over 40 years, described above, that low-titer group O whole blood 
can safely be used as a universal donor product and retains hemostatic capacity. The risk 
of hemolytic reaction when a patient initially transfused with unmatched group O whole 
blood later receives type-specific transfusion is mitigated by using low titer whole blood 
and by requiring that patients who have received uncrossmatched group O whole blood 
must receive a further 6 units of type-specific plasma transfused prior to receipt of type-
specific PRBCs to prevent a reaction. In the interim the patient will receive group O 
PRBCs.  There is also evidence that whole blood may be a superior hemostatic product 
compared to component therapy, and that it may reduce transfusion requirements, 
development of coagulopathy, and ultimately mortality. The risk-benefit profile of whole 
blood transfusion is therefore quite favorable.  The evidence for this analysis is described 
extensively in sections 1.1 and 1.2, Overview of Non-Clinical and Clinical Studies.  

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3 
STUDY OBJECTIVES 
3.1 
Primary Objective 
The primary objective is to assess the clinical efficacy of whole blood compared to 
component therapy for trauma patients requiring massive transfusion, as measured by 
volume of blood products transfused within the first 24 hours of admission.  
3.2 
Secondary Objectives 
The secondary objectives are to evaluate: 
1. Functional coagulopathy as measured by thromboelastography; 
2. 30-day mortality;  
3. Number of units of blood products transfused by component/product;  
4. Complications; 
5. Hemolysis; 
6. Wastage of blood units 
 
See Section 5 for definitions of primary and secondary endpoints.  
4 
STUDY DESIGN 
4.1 
Study Overview 
This is a single center, prospective cohort study.  Enrollment of approximately 98 
patients is planned, 49 receiving whole blood and 49 receiving component therapy. This 
is an observational study planned during initiation of a change in practice at our 
institution initially allowing up to 4 units of whole blood transfusion for adult male 
trauma patients.  If initial patients receiving whole blood show no evidence of hemolysis 
and thrombocytopenia compared to patients receiving component therapy, up to 6 units 
of whole blood transfusion will be allowed (see below, and section 5.2, Safety 
Evaluations).  Patients in the whole blood, or index, group are adult male trauma patients 
presenting in hemorrhagic shock (systolic blood pressure < 100) requiring massive 
transfusion activation who receive whole blood for resuscitation.  Two control groups 
will be utilized.  The prospective control group consists of adult male patients who 
present during times when whole blood is not available, as well as adult female patients, 
presenting in hemorrhagic shock (systolic blood pressure <100) requiring massive 
transfusion activation. Additionally, a second control group consisting of historical 

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controls receiving component therapy will be analyzed (see Section 6, Patient Selection, 
for details of index and control groups). 
 
All patients will have, in addition to standard labs, additional labs drawn for 
thromboelastography, platelet function determination, and coagulation factor levels (see 
Section 9.1.6, Other Clinical Procedures, for details of specific lab tests and timing).  
 
Patients who meet all inclusion criteria and none of the exclusion criteria will be 
enrolled into the study.  
 
Total duration of patient participation will be approximately 1 year (365 days), or 
the duration of the hospital stay, whichever is shorter.  This includes up to 5 days of 
laboratory testing during initial resuscitation and subsequent admission, and up to one 
year of follow up via chart review if the patient remains in the hospital.  Total duration of 
the study including recruitment and follow up is expected to be 2 years. 
5 
CRITERIA FOR EVALUATION 
5.1 
Primary Efficacy Endpoint 
The primary objective is to assess the clinical efficacy of whole blood compared to 
component therapy for trauma patients requiring massive transfusion. Primary analysis 
will compare volume of blood transfusion within 24 hours of admission for patients 
without severe TBI (defined as GCS ≤8 and imaging evidence of brain injury) for 
patients who received WB versus component therapy for initial resuscitation. 
Secondary Efficacy Endpoints 
The secondary objectives will evaluate the effect on survival; the development of 
multiple complications related to survival; and wastage data. The full list of secondary 
endpoints is as follows: 
1. Volume of blood transfusion within 24 hours of admission for patients with 
severe TBI (GCS ≤8 and imaging evidence of brain injury) and for entire cohort 
of patients. 
2. Thromboelastography parameters including maximum amplitude, reaction time, 
alpha angle, fibrinolysis, and platelet function at 3 and 6 hours of resuscitation, 
after every 6 units of whole blood equivalent (WB or PRBCs) given, at the time 
of completion of resuscitation (time of last unit of blood product given), and on 
ICU days 1, 3 and 5.  
3. 30-day mortality;  

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4. Duration of need for renal replacement therapy, mechanical ventilation, ICU 
admission, and hospital stay;  
5. Number of units of blood products transfused by component/product during first 
24 hours of admission and total hospitalization;  
6. Complications which include clinical coagulopathy, infection, venous 
thromboembolism, cerebrovascular accident, acute coronary syndrome, 
transfusion-related lung injury, transfusion-associated cardiac overload during 
total hospitalization; 
7. Hemolysis as measured by haptoglobin, bilirubin, lactate dehydrogenase, and 
direct antiglobulin on ICU day 1; 
8. Wastage of blood units 
5.2 
Safety Evaluations 
 Hemolysis will be measured by haptoglobin, bilirubin, lactate dehydrogenase, and 
direct antiglobulin tests on ICU day 1.  Clinical surveillance for evidence of 
hemolysis will also be ongoing.  The Blood and Blood Derivatives committee will 
review data for the first 10 patients to receive whole blood for evidence of hemolysis 
and thrombocytopenia.  If the risks of these conditions are judged by the Committee 
to be equivalent to risks seen following treatment with similar amounts of component 
therapy, the Committee will allow an increase from up to 4 units to up to 5 units of 
whole blood to be transfused. After 10 patients have received whole blood under this 
protocol, the Committee will again evaluate for hemolysis and thrombocytopenia and 
increase to a maximum of 6 units of whole blood if risks are found to be equivalent to 
component therapy.  
 
 Alternatively, should the safety of up to 4 units of whole blood be published before 
10 patients have received whole blood, the Committee will allow an increase to a 
maximum of 5 units of whole blood.  The Committee will assess the first 10 patients 
to receive whole blood under this protocol and if the risks of hemolysis and 
thrombocytopenia are judged by the Committee to be equivalent to risks seen 
following treatment with similar amounts of component therapy, the Committee will 
allow up to 6 units of whole blood to be transfused. 
 
 The Blood and Blood Derivatives Committee at UCLA, also known as the 
Transfusion Committee, is composed of Transfusion Medicine faculty members.  The 
Committee performs routine monthly monitoring of all transfusion-related safety 

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data, including evidence of hemolysis and other transfusion reactions. In addition, the 
Committee has agreed to perform a separate evaluation of the cohort of patients 
receiving whole blood and compare this to equivalent patients receiving component 
therapy (as defined in the inclusion and exclusion criteria for the study), for the 
purposes of evaluating the safety of whole blood.  Drs. Ziman and Ward, who are co-
investigators in this study, are members of the Blood and Blood Derivatives 
Committee but will be recused from safety analysis related to this study to prevent 
conflict of interest.  No other member of the Committee has a relationship to the 
study.  
 
 The incidence of adverse events will be evaluated including: death, clinical 
coagulopathy, hemolysis, infection, venous thromboembolism, cerebrovascular 
accident, acute coronary syndrome, transfusion-related lung injury, transfusion-
associated cardiac overload. 
 The occurrence of any whole blood transfusion given to patients other than adult male 
trauma patients will also be recorded 
 In addition to ongoing monitoring and final analysis, an interim safety analysis when 
approximately 50% of patients have been enrolled will determine if there is a 
difference in adverse events as defined above between groups. 
 The interim analysis will be performed by the independent medical monitor.  The 
independent medical monitor, Dr. William Mower, is an emergency medicine 
physician with extensive experience in clinical investigation and has no relation to the 
study other than to monitor safety. The independent medical monitor has the authority 
to stop the study if safety concerns arise, including but not limited to evidence for the 
pre-specified stopping criteria (see Section 12.5, Stopping Criteria). Dr. Mower is 
also independent of the Blood and Blood Derivatives Committee.   
 
6 
PATIENT SELECTION 
6.1 
Study Population  
All trauma patients who present with SBP<100 who require activation of the massive 
transfusion protocol and who do not have severe burns (>20% total body surface area) 
will be eligible for enrollment. 
Enrollment of male and female patients: 

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At UCLA and at least two other institutions 28 the standard of care for traumatic 
resuscitation for adult males is either: 
1) Low anti-A anti-B titer (<1:100) group O+ whole blood   
or, when whole blood is not available,  
2) Component therapy, consisting of group O+ PRBCs, group AB or A plasma, and 
untyped platelets 
The standard of care for adult females is component therapy, consisting of group O-
PRBCs, group AB or A plasma, and untyped platelets. Group O- whole blood is not 
available at our institution at this time. During a critical traumatic resuscitation, it is often 
impossible to determine precise age and menopausal status before initiation of 
transfusion.  In order to avoid any possibility of alloimmunization of reproductive-age 
females, the UCLA Blood and Blood Derivatives Committee has approved group O+ 
whole blood only for use in males.   
The index and control groups in the study therefore consist of: 
1) Index group: male trauma patients presenting with SBP<100 who require activation of 
the massive transfusion protocol and who do not have severe burns >20% TBSA who 
receive whole blood; 
2) Prospective control group: Prospectively-identified cohort of patients who present 
during the study with SBP<100 who require activation of the massive transfusion 
protocol and who do not have severe burns >20% TBSA but who are either not eligible or 
not able to receive whole blood.  This category consists of patients who are female (who 
are not eligible to receive whole blood) and male patients who present when whole blood 
is out of stock;  
3) Historical control group: male trauma patients who presented with SBP<100 who 
required activation of the massive transfusion protocol and who did not have severe burns 
>20% TBSA who received component therapy for traumatic hemorrhage requiring 
massive transfusion protocol activation, during the 5 years prior to initiation of the study.   
 
A mixed effects linear regression model will be used to adjust for confounding variables, 
including sex. 
Enrollment of patients of unknown precise age: 
Due to the emergent nature of a critical code trauma activation, it is often not possible to 
determine exact age of patients prior to initiating treatment, including transfusion, for 

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hemorrhaging patients.  Patients who appear to be adults, ie over age 18, will be eligible 
for inclusion in the study.  Every effort will be made to ensure that patients enrolled are at 
least 18 years old, while respecting the necessities of clinical care.  However, we 
acknowledge it is possible that there may be an instance where a patient is included who 
is not over age 18.   
 
6.2 
 Inclusion Criteria 
All trauma patients who present with SBP<100 who require activation of the massive 
transfusion protocol and who do not have severe burns (>20% total body surface area) 
will be eligible for enrollment.  The study plans to include all such patients who present 
during the study period of approximately 2 years. 
Within this group of patients, all adult male patients who received or will receive whole 
blood are eligible for inclusion in the whole blood group.  All adult male patients who 
received or will receive component therapy initially are eligible for inclusion in the 
component therapy group.  All adult female patients are eligible for inclusion in the 
component therapy group.   
6.3 
Exclusion Criteria 
1. Patients with burns over >20% total body surface area 
2. Patients who appear to be under age 18 
7 
CONCURRENT MEDICATIONS 
All patients should be maintained on the same medications throughout the entire study 
period, as medically feasible, with no introduction of new chronic therapies related to the 
study. 
7.1 
Allowed Medications and Treatments 
There are no prohibited medications or treatments. 
8 
STUDY TREATMENTS 
8.1 
Method of Assigning Patients to Treatment Groups 
Treatment groups are not assigned as this is an observational study.  Treatment is 
determined by the eligibility of the patient (male or female) and the availability of whole 
blood when the patient presents. Adult male patients meeting eligibility who have 

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received or will receive whole blood for traumatic resuscitation will be enrolled in the 
whole blood group. Enrollment of 49 patients receiving whole blood is planned.  Adult 
male patients meeting eligibility criteria who present when whole blood is not available 
will receive component therapy and will be enrolled in the component therapy group. 
Enrollment of 49 control (component therapy group) patients is planned. Female patients 
meeting eligibility criteria will also be included in the component therapy group (see 
Section 6.1, Study Population, for rationale).  
8.2 
Blinding 
The study is not blinded. 
8.3 
Formulation of Test and Control Products 
1. Test Product:   Low-antibody (anti-A/anti-B) titer ( <1:100) Group O+ banked whole 
blood stored at 1-6 °C for up to 10 days.   After collection, product undergoes infectious 
disease and immunohematology testing per regulatory requirements and leukocyte-
reduction with a platelet-sparing filter. 
2.  Control Product: Component therapy manufactured according to standard practices, 
consisting of packed red blood cells, thawed fresh frozen plasma and platelets in a 1:1:1 
ratio.   
8.3.1 
Packaging and Labeling 
Whole blood is supplied by the UCLA Blood Bank in bags containing approximately 250 
milliliters of product. It is labeled with a large-print, brightly-colored label identifying it 
as whole blood.  
8.4 
Supply of Study Drug at the Site 
The UCLA Blood & Platelet Center will identify repeat volunteer male whole blood 
donors to maintain a predetermined inventory of 12 units of low-titer (<1:100) O-positive 
whole blood.  These donors will be identified by titering the retention samples from a 
prior donation.  The study will be explained to potential donors as a recruitment tool.   
All donors of whole blood units will be tested for transfusion-transmitted infectious 
diseases, identical to the AABB and FDA regulations for all blood donors.  Donor 
infectious disease testing is performed at CTS (Creative Testing Solutions) in Tempe, 
Arizona; the average tum-around time for completion of testing and blood availability in 
inventory is 48 hours. Whole blood units will undergo pre-storage leukoreduction with a 
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for 10 days. If not used by day 10, units will be fractionated into PRBC units to be 
released into general inventory for transfusion, and plasma which will be discarded.  
The goal is to maintain up to 12 units of low-titer type O-positive whole blood weekly.  6 
units will be stored in the Trauma Bay blood refrigerator, and 6 units will be stored in the 
blood bank.  
8.4.1 
Dosage/Dosage Regimen 
Adult male patients may receive up to 4 units of whole blood if needed during initial 
traumatic resuscitation in the initial phase of the study, and up to 6 units if deemed to be 
safe (see section 5.2, Safety Evaluations).  
8.4.2 
Dispensing 
The blood bank dispenses all blood products. 
8.4.3 
Administration Instructions  
Blood products are transfused intravenously.  
8.4.4 Storage 
Whole blood will be stored by the study site in a refrigerator designated for the storage of 
blood products maintained at 1-6ºC. If the temperature of study drug storage in the 
clinic/pharmacy exceeds or falls below or above this range, this will be reported to the 
Sponsor/Investigator or designee and captured as a deviation. 
8.5 
Study Drug Accountability 
An accurate and current accounting of the dispensing and return of study drug for each 
patient will be maintained on an ongoing basis by a member of the study site staff at the 
blood bank.  The amount of study drug dispensed and returned will be recorded in blood 
bank accountability records.  The study monitor will verify these documents throughout 
the course of the study. 
9 
STUDY PROCEDURES AND GUIDELINES 
A Schedule of Events representing the required testing procedures to be performed for 
the duration of the study is diagrammed in Appendix 1. 
Due to the emergent nature of treatment, and the fact that both whole blood and 
component therapy are considered standard of care for traumatic resuscitation of adult 
males, the UCLA Institutional Review Board has waived the requirement for informed 

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consent and Health Insurance Portability and Accountability Act (HIPAA) authorization.  
As an FDA approved product, whole blood is not considered an investigational treatment 
by the Institutional Review Board and therefore these requirements have been waived for 
the entire study.  Patients will be informed of which product they received and of the 
study by their clinical providers, but not directly by study personnel.  
9.1 
Clinical Assessments 
9.1.1 Concomitant Medications 
All concomitant medication and concurrent therapies will be documented on admission 
or as soon as possible thereafter.  Dose, route, unit frequency of administration, and 
indication for administration and dates of medication will be captured. 
9.1.2 
Demographics  
Demographic information (date of birth, gender, race) will be recorded on admission. 
9.1.3 
Medical History  
Relevant medical history, including history of current disease, other pertinent respiratory 
history, and information regarding underlying diseases will be recorded on admission. 
9.1.4 Vital Signs 
Body temperature, blood pressure, pulse and respirations will be recorded on admission 
and at least every 4 hours thereafter while the patient is in the ICU. 
9.1.5 Oximetry 
Oximetry will be measured on room air on admission. 
9.1.6 Other Clinical Procedures 
 All patients will have, in addition to standard labs, additional labs drawn for 
thromboelastography, platelet function determination, and coagulation factor levels, on 
admission, after each 6 units of whole blood or PRBCs transfused, at 3 and 6 hours of 
resuscitation, at the time of hemostasis, and on ICU days 1,3 and 5.  Tests for hemolysis 
will be performed along with regular clinical labs on ICU day 1. These labs will be drawn 
during clinical lab collection so no extra needle stick is required.   

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9.1.7 Adverse Events 
Information regarding occurrence of adverse events will be captured throughout the 
study. Duration (start and stop dates and times), severity/grade, outcome, treatment and 
relation to study drug will be recorded on the case report form (CRF).   
Morbidity and mortality in this study population (patients requiring massive transfusion 
for trauma) is high. 29 Therefore we expect a relatively large number of adverse events, 
and resulting SAE reports, for reasons unrelated to the study.   
9.2 
Clinical Laboratory Measurements  
9.2.1 
Hematology 
Patients will receive standard hematology tests including complete blood counts as 
standard of care no less than daily (see also Schedule of Events). 
9.2.2 
Blood Chemistry Profile 
Patients will receive this no less than daily as standard of care.  
9.2.3 
Pregnancy Test 
Female patients of childbearing age will receive this on admission or shortly thereafter as 
standard of care.  
9.3 
Research Laboratory Measurements  
9.3.1 Thromboelastography (TEG)/platelet mapping 
For TEG testing, 1 mL of patient blood sample will be added to a plastic vial 
containing kaolin.  The vial will be capped securely and the contents will be 
mixed by gentle inversion.  340 microliters of the resultant mixture will be 
pipetted into a disposable TEG cup containing 20 microliters of calcium 
chloride preloaded in the TEG. To minimize any risk of splashing, personnel 
will use standard personal protective equipment. The cup will be raised into the 
TEG chamber and testing will begin.  Platelet mapping assesses platelet function 
by repeating TEG parameters in the presence of platelet activators and 
inhibitors. After approximately 30 minutes, testing is complete.  The TEG 
apparatus is completely enclosed. All syringes, pipettes, and cups used for this 
procedure will be placed in a biohazard container.   
 
9.3.2 Calibrated Automated Thromboelastogram (CAT) testing 

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For CAT testing, blood not used for TEG will be transferred to 5 mL plastic 
centrifuge tubes.  The tubes will be capped securely and centrifuged.  The 
resulting plasma will be transferred to plastic cryotubes, which are enclosed, and 
frozen until testing.  All syringes, pipettes, and centrifuge tubes will be placed in 
a biohazard container.80 microliters of thawed plasma will be pipetted to each 
well of a 96-well plate (less wells used for controls). The plate is then placed in 
the CAT for testing, which is enclosed.  At the end of the CAT testing cycle, the 
plate and pipettes will be placed in a biohazard container. All transfers of 
potentially biohazardous material will take place in a biosafety cabinet to 
minimize the risk of splashes. At all times during laboratory testing, proper PPE 
will be worn and, at the end of each testing day, laboratory surfaces will be 
disinfected according to protocol. 
10 
EVALUATIONS BY VISIT 
10.1 
Visit 1 (Days 1-365)  
Hospital Stay visit: typically 1-14 days, but can be as long as one year. 
1. 
Assign the patient a unique study number.  This number is planned to be listed on a 
bracelet in a packet present in the ED.  The bracelet will be placed on the patient’s 
wrist during initial admission procedures to identify the patient as a participant in 
the study.   
2. 
All demographic data, past medical history, and concurrent medications are 
recorded by hospital staff as part of standard admission procedures.  This 
information will be reviewed by study personnel during analysis.  
3. 
Physical examination, vital signs, and standard clinical labs are performed and 
recorded by hospital staff. 
4. 
Additional blood samples will be collected for TEG/platelet mapping and CAT 
(one 4 mL sodium citrate and one 4 mL heparinized tube per draw).  This will be 
performed at the following time points: on admission, after each 6 units of whole 
blood equivalent (WB or PRBCs) transfused, at 3 and 6 hours of resuscitation, at 
the time of hemostasis determined by the trauma surgeon, and on ICU days 1,3 and 
5. 
5. 
Standard clinical labs including complete blood counts (white blood cell count, 
hemoglobin, hematocrit, and platelet count), blood chemistries, and standard 
coagulation labs (prothrombin time, international normalized ratio, partial 
thromboplastin time) will be performed at least daily as standard of care.  This data 
will also be collected as part of the study.  Of note, serial platelet counts obtained 

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as standard of care will be monitored no less frequently than daily at noon (see also 
Schedule of Events).  
6. 
In addition to standard clinical labs, hemolysis labs will be performed as listed 
above on ICU day 1 which will be billed to the study. 
7. 
Follow up by chart review will continue for the duration of the hospital stay 
(typically roughly 14 days but can be up to one year). 
8. 
Chart review during the hospital stay will collect the following data:  
Data collected on initial 24 hours of hospital stay: 
Medical record number  
Date of birth /age 
Sex 
Race 
Weight 
Height 
Injury date/time 
Arrival date/time 
Emergency Department exit date/time 
Operating room arrival time 
Tier (defines levels of critical condition for trauma patients) 
Injury description 
Mechanism of injury 
Injury Severity Score 
Glasgow Coma Scale and vitals 
Intubation status and location of intubation 
Whether patient received cardiopulmonary resuscitation  
Total fluids received in the first 24 hours 
 
Data collected on initial 5 days of hospitalization: 
Vital signs: systolic and diastolic blood pressure, heart rate, respiratory 
rate, oxygen saturation, temperature 
Hemoglobin 
Hematocrit 

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White blood cell count 
Platelet count 
Sodium 
Potassium 
Chloride 
Bicarbonate 
Blood urea nitrogen 
Creatinine 
Glucose 
Aspartate transaminase (AST) 
Alanine transaminase (ALT) 
Total bilirubin 
Direct bilirubin 
Alkaline phosphatase 
pH 
Lactate 
PaCO2 (arterial CO2 partial pressure) 
PaO2 (arterial oxygen partial pressure) 
Base excess 
Prothrombin time (PT) 
INR 
Partial thromboplastin time (PTT) 
Fibrinogen 
Thrombin 
Antithrombin Complex 
Factor V 
Factor VII 
Factor VIII 
Factor X 
D-dimer 
Lactate dehydrogenase (LDH) 

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Haptoglobin 
 
 
Data collected on entire hospitalization:  
Procedures performed during hospitalization 
Operations performed during hospitalization 
Discharge date 
Disposition 
Discharge capacity 
Date and cause of death if applicable 
Comorbidities  
Admission medications 
Total hospital and intensive care unit length of stay 
Number of days on ventilator  
Number of days on dialysis 
Number of days on vasopressor medications 
Number and nature of operative procedures 
Development of venous thromboembolism 
Development of acute kidney injury 
Development of acute respiratory distress syndrome  
Development of liver failure 
Suspected or confirmed transfusion reaction 
Hemolytic transfusion reaction 
Transfusion associated lung injury 
Development of cardiac failure 
Development of clinical coagulopathy  
11 
ADVERSE EXPERIENCE REPORTING AND DOCUMENTATION 
11.1 
Adverse Events 
An adverse event (AE) is any untoward medical occurrence in a clinical investigation of a 
patient administered a pharmaceutical product and that does not necessarily have a causal 

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relationship with the treatment.  An AE is therefore any unfavorable and unintended sign 
(including an abnormal laboratory finding), symptom or disease temporally associated 
with the administration of an investigational product, whether or not related to that 
investigational product.   
The Investigator and Independent Medical Monitor will probe, via discussion with the 
patient’s clinical providers, for the occurrence of AEs during the patient visit and record 
the information in the site’s source documents.  Adverse events will be recorded in the 
patient CRF.  Adverse events will be described by duration (start and stop dates and 
times), severity, outcome, treatment and relation to study drug, or if unrelated, the cause.  
AE Severity 
The National Cancer Institute’s Common Terminology Criteria for Adverse Events 
(CTCAE) Version 3.0 will be used to assess and grade AE severity, including laboratory 
abnormalities judged to be clinically significant. The guidelines shown in Table 1 below 
will be used to grade severity.  It should be pointed out that the term “severe” is a 
measure of intensity and that a severe AE is not necessarily serious. 
Table 1.  AE Severity Grading 
Severity (Toxicity Grade) 
Description 
Mild (1) 
Transient or mild discomfort; no limitation in activity; no medical 
intervention or therapy required. The patient may be aware of the sign 
or symptom but tolerates it reasonably well. 
Moderate (2) 
Mild to moderate limitation in activity, no or minimal medical 
intervention/therapy required. 
Severe (3) 
Marked limitation in activity, medical intervention/therapy required, 
hospitalizations possible. 
Life-threatening (4) 
The patient is at risk of death due to the adverse experience as it 
occurred. This does not refer to an experience that hypothetically 
might have caused death if it were more severe. 
 
AE Relationship to Study Drug 
The relationship of an AE to the study drug should be assessed using the following the 
guidelines in Table 2. 

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Table 2.  AE Relationship to Study Drug 
Relationship 
to Drug 
Comment 
Definitely 
Previously known toxicity of agent; or an event that follows a reasonable temporal 
sequence from administration of the drug; that follows a known or expected response 
pattern to the suspected drug; that is confirmed by stopping or reducing the dosage 
of the drug; and that is not explained by any other reasonable hypothesis. 
Probably 
An event that follows a reasonable temporal sequence from administration of the 
drug; that follows a known or expected response pattern to the suspected drug; that is 
confirmed by stopping or reducing the dosage of the drug; and that is unlikely to be 
explained by the known characteristics of the patient’s clinical state or by other 
interventions. 
Possibly 
An event that follows a reasonable temporal sequence from administration of the 
drug; that follows a known or expected response pattern to that suspected drug; but 
that could readily have been produced by a number of other factors. 
Unrelated 
An event that can be determined with certainty to have no relationship to the study 
drug. 
11.2 
Serious Adverse Experiences (SAE) 
An SAE is defined as any AE occurring at any dose that results in any of the following 
outcomes: 
● death 
● a life-threatening adverse experience 
● inpatient hospitalization or prolongation of existing hospitalization 
● a persistent or significant disability/incapacity 
● a congenital anomaly/birth defect  
Other important medical events may also be considered an SAE when, based on 
appropriate medical judgment, they jeopardize the patient or require intervention to 
prevent one of the outcomes listed.  
 

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11.2.1 Serious Adverse Experience Reporting 
Study site will document all SAEs that occur (whether or not related to study drug) per 
UCLA OHRPP Guidelines.  The collection period for all SAEs will begin after admission 
and end after discharge. 
In accordance with the standard operating procedures and policies of the Institutional 
Review Board, the site investigator will report SAEs to the IRB.   
11.3 
Protocol Defined Important Medical Findings Requiring Real Time 
Reporting 
The following additional event is to be reported in real time to the IRB and FDA: 
Hemolytic transfusion reactions:  Defined as a clinical syndrome within 24 hours of 
blood transfusion including one or more symptoms (back pain, shortness of breath, 
hematuria, chills, dizziness, fever, urticaria) with clinical or laboratory evidence of 
hemolysis (hematuria, decreased haptoglobin, increased lactate dehydrogenase or 
bilirubin, or positive direct antigen test).  Requires immediate cessation of ongoing blood 
transfusion and reporting as SAE.  
11.4 
Medical Monitoring 
The Sponsor/Investigator, as well as the Independent Medical Monitor, will monitor for 
adverse effects and should be contacted directly to report medical concerns or questions 
regarding safety:  Medical monitor (Dr. William Mower) phone: (310) 825-2111 e-mail: 
wmower@mednet.ucla.edu 
12 
DISCONTINUATION AND REPLACEMENT OF PATIENTS 
12.1 
Early Discontinuation of Study Drug  
A patient may be discontinued from study treatment at any time if the patient, or 
Sponsor/Investigator feels that it is not in the patient’s best interest to continue.  The 
following is a list of possible reasons for study treatment discontinuation:  
 Hemolytic transfusion reaction 
 Adverse event that in the opinion of the Sponsor/Investigator would be in the best 
interest of the patient to discontinue study treatment 
 Protocol violation requiring discontinuation of study treatment 

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If a patient is withdrawn from treatment due to an adverse event, the patient will be 
followed and treated by the Sponsor/Investigator until the abnormal parameter or 
symptom has resolved or stabilized.   
12.3 
Withdrawal of Patients from the Study 
A patient may be withdrawn from the study at any time if the patient or the 
Sponsor/Investigator feels that it is not in the patient’s best interest to continue.   
All patients are free to withdraw from participation at any time, for any reason, specified 
or unspecified, and without prejudice. 
Reasonable attempts will be made by the Sponsor/Investigator to provide a reason for 
patient withdrawals.  The reason for the patient’s withdrawal from the study will be 
specified in the patient’s source documents.    
12.4 
Replacement of Patients 
 
Patients who withdraw from the study will be replaced.   
12.5 
Stopping Criteria 
Pre-specified stopping criteria are as follows: 
1. Hemolytic transfusion reaction: Defined as a clinical syndrome within 24 hours of 
blood transfusion including one or more symptoms (back pain, shortness of breath, 
hematuria, chills, dizziness, fever, urticaria) with clinical or laboratory evidence of 
hemolysis (hematuria, decreased haptoglobin, increased lactate dehydrogenase or 
bilirubin, or positive direct antigen test).  Requires immediate cessation of ongoing blood 
transfusion and reporting as SAE.  As this is an unexpected and serious event, any 
hemolytic transfusion reaction following the administration of whole blood will prompt 
temporary cessation of the study while the event is evaluated.  If the event indeed 
occurred after administration of low titer group O-positive whole blood, the study will be 
stopped.  
 
2. Additionally, interim analysis will seek evidence for increased incidence of clinical 
coagulopathy, increased transfusion requirements, and increased incidence of 
complications as defined above in Secondary Endpoints, or increased mortality, all of 
which will prompt stopping the study.  

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13 PROTOCOL VIOLATIONS 
A protocol violation occurs when the patient or Sponsor/Investigator fails to adhere to 
significant protocol requirements affecting the inclusion, exclusion, patient safety and 
primary endpoint criteria.  Protocol violations for this study include, but are not limited 
to, the following: 
● Failure to meet inclusion/exclusion criteria 
● Switching from component therapy to whole blood 
Failure to comply with Good Clinical Practice (GCP) guidelines will also result in a 
protocol violation. The Sponsor/Investigator will determine if a protocol violation will 
result in withdrawal of a patient. 
When a protocol violation occurs, it will be discussed with the Sponsor/Investigator and a 
Protocol Violation Form detailing the violation will be generated. This form will be 
signed by a Sponsor/Investigator or representative. A copy of the form will be filed in the 
site’s regulatory binder and in the Sponsor/Investigator’s files. 
14 
DATA SAFETY MONITORING 
The UCLA Institutional Review Board has approved an Independent Medical Monitor, 
Dr William Mower.  The Sponsor/Investigator and Independent Medical Monitor will 
review clinical data and probe for evidence of adverse events via discussion with the 
patient’s clinical providers as described above. An interim analysis for safety is planned 
when approximately 50% of patients have been enrolled.  The monitor will also ensure 
that records are maintained appropriately throughout the study. 
15 
STATISTICAL METHODS AND CONSIDERATIONS 
Prior to the analysis of the final study data, a detailed Statistical Analysis Plan (SAP) will 
be written describing all analyses that will be performed.  The SAP will contain any 
modifications to the analysis plan described in this protocol.   
15.1 
Data Sets Analyzed 
All eligible patients who are enrolled in the study and receive at least one unit of blood, 
and who undergo TEG testing as described above, will be included in analysis.  
 
Data sets include: 

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1.  Prospectively identified patients who received whole blood or component therapy and 
did not have severe TBI 
2. Prospectively identified patients who received whole blood or component therapy and 
who had severe TBI (GCS 8 or less with evidence of brain injury on imaging) 
3. Prospectively identified patients who received whole blood or component therapy, all 
patients regardless of TBI status 
4. Prospectively identified male patients who received whole blood and who did not have 
severe TBI, compared to historical control male patients who received component 
therapy and who did not have severe TBI 
 
 
15.2 
Demographic and Baseline Characteristics 
The following demographic variables will be summarized: age, sex, race, height and 
weight, comorbidities, and home medications. 
15.3 
Analysis of Primary Endpoint 
Primary analysis compares volume of blood products transfused in the first 24 hours of 
admission in patients without severe TBI (severe TBI is defined as GCS ≤8 and evidence 
of brain injury on imaging) receiving whole blood versus component therapy during 
initial resuscitation. 
For continuous variables including the primary endpoint, the statistical method will 
depend on the distribution of the data.  If the data appears to follow a normal distribution, 
a t-test will be used, otherwise, a nonparametric Wilcoxian rank sum test will be used.   
15.4 
Analysis of Secondary Endpoints 
Continuous variables and categorical variables will be analyzed as described above 
(section 15.3). Mixed effects linear regression models will be used to evaluate 
coagulopathy over time and to adjust for confounding variables.  
To analyze coagulopathy over time we will use a mixed effects linear regression model.  
A mixed effects linear regression model will also be used to adjust for confounding 
variables such as sex, age, comorbidities, severity of injury, and physiologic parameters 
of shock including pH and temperature, and use of a rapid transfuser (which more 
effectively warms blood).   
Quarterly safety monitoring will compare categorical variables including mortality and 
development of complications (duration of need for renal replacement therapy, 

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mechanical ventilation, ICU admission, and hospital stay; clinical coagulopathy, 
infection, venous thromboembolism, cerebrovascular accident, acute coronary syndrome, 
transfusion-related lung injury, transfusion-associated cardiac overload; transfusion 
reactions including clinical transfusion reactions and rates of hemolysis as measured by  
haptoglobin, bilirubin, lactate dehydrogenase, and direct antiglobulin). Categorical 
variables will be compared using the chi-squared test.  
15.5 
Interim Analysis 
When approximately 50% of patients have been enrolled in the study, an interim analysis 
for safety is planned to be conducted by the independent medical monitor. (See Section 
5.2, Safety Evaluations).  
 
Sample Size  
Number of patients to be enrolled was calculated using a Type I error rate of 0.05, and 
effect size based on reduction of PRBC and plasma transfusions described in the 
sensitivity analysis in a study by Cotton et al. 1  
 
As in the sensitivity analysis by Cotton et al, patients with severe TBI (defined as TBI on 
imaging with GCS of 8 or less) will be excluded from primary analysis.  Approximately 
35-40% of patients meeting inclusion criteria are expected to fulfill criteria for severe 
TBI. It is not possible to identify patients with severe TBI prior to beginning resuscitation 
for hemorrhagic shock, so all patients meeting inclusion criteria will be enrolled. In the 
primary analysis, only patients without severe TBI will be compared.  Secondary 
analyses will compare 1) patients with severe TBI receiving WB versus component 
therapy and 2) the entire cohort of enrolled patients, with and without TBI, receiving WB 
versus component therapy.  Using this method, a total sample size of 49 whole blood arm 
(study drug) and 49 component therapy arm (control) patients (98 patients total) is 
planned.  35-40% (approximately 18 of the total 49) of eligible patients are expected to 
have severe TBI and to be excluded from primary analysis based on typical presentations 
of trauma patients. 49 total patients per group will achieve a sample size of 
approximately 31 patients per arm without TBI to complete the primary analysis. The 
FDA will be notified in advance if sample size estimates change.  

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16 
DATA COLLECTION, RETENTION AND MONITORING 
16.1 
Data Collection Instruments 
The Sponsor/Investigator will prepare and maintain adequate and accurate source 
documents designed to record all observations and other pertinent data for each patient 
treated with the study drug.   
Study personnel will enter data from source documents corresponding to a patient’s visit 
into the protocol-specific electronic database containing the electronic Case Report Form 
(eCRF) when the information corresponding to that visit is available.  Patients will not be 
identified by name in the study database or on any study documents to be collected by the 
Sponsor/Investigator (or designee), but will be identified by a patient number. 
If a correction is required for an eCRF, the time and date stamps track the person entering 
or updating eCRF data and creates an electronic audit trail.   
The Sponsor/Investigator is responsible for all information collected on patients enrolled 
in this study.  All data collected during the course of this study must be reviewed and 
verified for completeness and accuracy by the Sponsor/Investigator.  A copy of the CRF 
will remain at the Sponsor/Investigator’s site at the completion of the study. 
16.2 
Data Management Procedures 
The data will be entered into a validated database.  The Data Management group will be 
responsible for data processing, in accordance with procedural documentation.  Database 
lock will occur once quality assurance procedures have been completed. 
All procedures for the handling and analysis of data will be conducted using good 
computing practices meeting FDA guidelines for the handling and analysis of data for 
clinical studies. 
16.3 
Data Quality Control and Reporting 
The study database utilizes REDCap, a secure platform for electronic data capture. After 
data have been entered into the study database, a system of computerized data validation 
checks will be implemented and applied to the database on a regular basis. Queries are 
entered, tracked, and resolved through the system directly.  
16.4 
Archival of Data 
The database is safeguarded against unauthorized access by established security 
procedures; appropriate backup copies of the database and related software files will be 

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maintained.  Databases are backed up by the database administrator in conjunction with 
any updates or changes to the database.   
At critical junctures of the protocol (e.g., production of interim reports and final reports), 
data for analysis is locked and cleaned per established procedures. 
16.5 
Availability and Retention of Investigational Records 
The Sponsor/Investigator must make study data accessible to the IRB, and Regulatory 
Agency (e.g., FDA) inspectors upon request. The Sponsor/Investigator must ensure the 
reliability and availability of source documents from which the information on the CRF 
was derived. 
16.6 
Monitoring 
Monitoring will be conducted the Independent Medical Monitor, the Sponsor/Investigator 
and associated staff according to the U.S. CFR Title 21 Parts 50, 56, and 312 and ICH 
Guidelines for GCP (E6).  
16.7 
Patient Confidentiality 
In order to maintain patient confidentiality, only a patient number and date of birth will 
identify all study patients in the electronic database/eCRF and other documentation.   
17 
ADMINISTRATIVE, ETHICAL, REGULATORY CONSIDERATIONS 
The study will be conducted according to the Declaration of Helsinki, Protection of 
Human Volunteers (21 CFR 50), Institutional Review Boards (21 CFR 56), and 
Obligations of Clinical Investigators (21 CFR 312). 
To maintain confidentiality, all study records will be kept in a secured database. Clinical 
information will not be released without written permission of the patient, except as 
necessary for monitoring by the FDA.  The Sponsor/Investigator must also comply with 
all applicable privacy regulations (e.g., Health Insurance Portability and Accountability 
Act of 1996, EU Data Protection Directive 95/46/EC).  De-identified data will be made 
available to other investigators. 
17.1 
Protocol Amendments 
Any amendment to the protocol will be written by the Sponsor/Investigator.  Protocol 
amendments cannot be implemented without prior written IRB approval except as 
necessary to eliminate immediate safety hazards to patients.  A protocol amendment 

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intended to eliminate an apparent immediate hazard to patients may be implemented 
immediately, provided the IRBs are notified within five working days. 
17.2 
Institutional Review Board 
The protocol has been reviewed and approved by the IRB.  Serious adverse experiences 
regardless of causality will be reported to the IRB in accordance with the standard 
operating procedures and policies of the IRB, and the Sponsor/Investigator will keep the 
IRB informed as to the progress of the study.  The Sponsor/Investigator will obtain 
assurance of IRB compliance with regulations. 
Any documents that the IRB may need to fulfill its responsibilities (such as protocol, 
protocol amendments, payment or compensation procedures, or other pertinent 
information) have been submitted to the IRB.  The IRB’s written unconditional approval 
of the study protocol and waiver of the informed consent form are confirmed to be in the 
possession of the Sponsor/Investigator prior to study initiation.  The IRB unconditional 
approval statement has been transmitted to the Sponsor/Investigator or designee prior to 
the shipment of study supplies to the site.  This approval refers to the study by exact 
protocol title and number and identifies the documents reviewed and the date of review. 
Protocol and/or informed consent modifications or changes may not be initiated without 
prior written IRB/ approval except when necessary to eliminate immediate hazards to the 
patients or when the change(s) involves only logistical or administrative aspects of the 
study.  Such modifications will be submitted to the IRB and written verification that the 
modification was submitted and subsequently approved should be obtained.   
The IRB must be informed of revisions to other documents originally submitted for 
review; serious and/or unexpected adverse experiences occurring during the study in 
accordance with the standard operating procedures and policies of the IRB; new 
information that may affect adversely the safety of the patients of the conduct of the 
study; an annual update and/or request for re-approval; and when the study has been 
completed. 
17.3 
Waiver of Informed Consent 
Informed consent and HIPAA authorization have been waived by the Institutional 
Review Board because 1) both whole blood and component therapy are considered 
standard of care for adult male trauma patients, and availability of whole blood (as well 
as patient gender) determines which therapy a patient will receive; and 2) due to the 
emergent nature of traumatic resuscitation, it is not possible to inform patients of the 

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study prior to initiating study-related testing (additional blood draw for TEG) or prior to 
initiation of therapy by the clinical team.  
18 
PUBLICATIONS 
The preparation and submittal for publication of manuscripts containing the study results 
shall be in accordance with a process determined by mutual written agreement among the 
study Sponsor/Investigator and participating institution.  The publication or presentation 
of any study results shall comply with all applicable privacy laws, including, but not 
limited to, the Health Insurance Portability and Accountability Act of 1996.  
19 Investigator Responsibilities 
By signing the Agreement of Investigator form, the Sponsor/Investigator agrees to: 
1. Conduct the study in accordance with the protocol and only make changes after 
notifying the Sponsor/Investigator (or designee), except when to protect the safety, 
rights or welfare of patients. 
2. Personally conduct or supervise the study (or investigation). 
3. Ensure that the requirements relating to obtaining informed consent and IRB review 
and approval meet federal guidelines, as stated in § 21 CFR, parts 50 and 56. 
4. Report any AEs that occur in the course of the study, in accordance with §21 CFR 
312.64. 
5. Ensure that all associates, colleagues and employees assisting in the conduct of the 
study are informed about their obligations in meeting the above commitments. 
6. Maintain adequate and accurate records in accordance with §21 CFR 312.62 and to 
make those records available for inspection  
7. Ensure that an IRB that complies with the requirements of §21 CFR part 56 will be 
responsible for initial and continuing review and approval of the clinical study. 
8. Promptly report to the IRB all changes in the research activity and all unanticipated 
problems involving risks to patients or others (to include amendments and IND 
safety reports). 
9. Seek IRB approval before any changes are made in the research study, except when 
necessary to eliminate hazards to the patients/patients. 
10. Comply with all other requirements regarding the obligations of clinical investigators 
and all other pertinent requirements listed in § 21 CFR part 312. 

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20 
Appendix I: Schedule of Events 
Assessment 
Baseline, 
Enrollment, 
Initial 
Resuscitation: 
Visit 1 (Day 0) 
Ongoing  
assessment: 
Visit 1 
(Daily 
monitoring 
throughout 
hospital 
stay)  
Laboratory 
assessment: 
Visit 1 
(Noon on 
ICU day 1) 
Laboratory 
assessment: 
Visit 1 
(Daily at 
noon, ICU 
days 1,3,5) 
Follow 
up by 
Chart 
Review: 
Visit 1 
(Day 0 -
365) 
Informed Consent Form   N/A  
  
 
 
  
Demographics 
 X 
  
 
 
  
Trauma characteristics 
X  
  
 
 
 X 
Medical History  
X  
  
 
 
 X 
Current Medications 
X 
  
 
 
  
Blood Chemistries 
X 
X 
 
 
  
Hematology/complete 
blood counts including 
serial platelet count 
monitoring 
X 
X 
 
 
 
TEG/platelet mapping 
and CAT testing 
X 
 
 
X 
 
Hemolysis testing 
 
 
X 
 
 
Standard coagulation 
labs 
X 
X 
 
 
 
Fluid and blood product 
resuscitation volume 
X 
 
 
 
X  
Vital Signs 
X 
X 
 
 
 
Inclusion/Exclusion 
Criteria  
X 
  
 
 
  
Enrollment 
X 
  
 
 
  
Concomitant 
Medications 
X 
 
 
 
X 
Clinical outcomes 
 
 
 
 
X 
Discharge information 
 
 
 
 
X 

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Adverse Events  
X 
X 
 
 
X 
Operations/Procedures 
X 
X 
 
 
X 
 
21 REFERENCES 
REFERENCES 
 
1. 
Cotton BA, Podbielski J, Camp E, et al. A randomized controlled pilot trial of 
modified whole blood versus component therapy in severely injured patients 
requiring large volume transfusions. Annals of surgery. 2013;258(4):527-532; 
discussion 532-523. 
2. 
Frith D, Brohi K. The acute coagulopathy of trauma shock: clinical relevance. The 
surgeon : journal of the Royal Colleges of Surgeons of Edinburgh and Ireland. 
2010;8(3):159-163. 
3. 
Nunez TC, Young PP, Holcomb JB, Cotton BA. Creation, implementation, and 
maturation of a massive transfusion protocol for the exsanguinating trauma 
patient. The Journal of trauma. 2010;68(6):1498-1505. 
4. 
Sambasivan CN, Schreiber MA. Emerging therapies in traumatic hemorrhage 
control. Current opinion in critical care. 2009;15(6):560-568. 
5. 
Shaz BH, Dente CJ, Harris RS, MacLeod JB, Hillyer CD. Transfusion 
management of trauma patients. Anesthesia and analgesia. 2009;108(6):1760-
1768. 
6. 
Spinella PC. Warm fresh whole blood transfusion for severe hemorrhage: U.S. 
military and potential civilian applications. Critical care medicine. 2008;36(7 
Suppl):S340-345. 
7. 
Brohi K, Singh J, Heron M, Coats T. Acute traumatic coagulopathy. The Journal 
of trauma. 2003;54(6):1127-1130. 
8. 
Burruss S TA, Hiatt J, Cryer H.  . Factors associated with mortality in massively 
transfused trauma patients.  . AAST 2010. Boston MA.  Poster Presentation. 2010. 
9. 
Borgman MA, Spinella PC, Perkins JG, et al. The ratio of blood products 
transfused affects mortality in patients receiving massive transfusions at a combat 
support hospital. The Journal of trauma. 2007;63(4):805-813. 
10. 
Armand R, Hess JR. Treating coagulopathy in trauma patients. Transfusion 
medicine reviews. 2003;17(3):223-231. 

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11. 
Ciavarella D, Reed RL, Counts RB, et al. Clotting factor levels and the risk of 
diffuse microvascular bleeding in the massively transfused patient. British journal 
of haematology. 1987;67(3):365-368. 
12. 
Spahn DR, Rossaint R. Coagulopathy and blood component transfusion in 
trauma. British journal of anaesthesia. 2005;95(2):130-139. 
13. 
Watson GA, Sperry JL, Rosengart MR, et al. Fresh frozen plasma is 
independently associated with a higher risk of multiple organ failure and acute 
respiratory distress syndrome. The Journal of trauma. 2009;67(2):221-227; 
discussion 228-230. 
14. 
Spinella PC, Pidcoke HF, Strandenes G, et al. Whole blood for hemostatic 
resuscitation of major bleeding. Transfusion. 2016;56 Suppl 2:S190-202. 
15. 
Pidcoke HF, Spinella PC, Ramasubramanian AK, et al. Refrigerated platelets for 
the treatment of acute bleeding: a review of the literature and reexamination of 
current standards. Shock (Augusta, Ga.). 2014;41 Suppl 1:51-53. 
16. 
Jobes D, Wolfe Y, O'Neill D, et al. Toward a definition of "fresh" whole blood: 
an in vitro characterization of coagulation properties in refrigerated whole blood 
for transfusion. Transfusion. 2011;51(1):43-51. 
17. 
Pidcoke HF, McFaul SJ, Ramasubramanian AK, et al. Primary hemostatic 
capacity of whole blood: a comprehensive analysis of pathogen reduction and 
refrigeration effects over time. Transfusion. 2013;53 Suppl 1:137s-149s. 
18. 
Snyder EL, Whitley P, Kingsbury T, Miripol J, Tormey CA. In vitro and in vivo 
evaluation of a whole blood platelet-sparing leukoreduction filtration system. 
Transfusion. 2010;50(10):2145-2151. 
19. 
Strandenes G, Austlid I, Apelseth TO, et al. Coagulation function of stored whole 
blood is preserved for 14 days in austere conditions: A ROTEM feasibility study 
during a Norwegian antipiracy mission and comparison to equal ratio 
reconstituted blood. The journal of trauma and acute care surgery. 2015;78(6 
Suppl 1):S31-38. 
20. 
Yazer MH, Glackin EM, Triulzi DJ, Alarcon LH, Murdock A, Sperry J. The 
effect of stationary versus rocked storage of whole blood on red blood cell 
damage and platelet function. Transfusion. 2016;56(3):596-604. 
21. 
Nair PM, Pidcoke HF, Cap AP, Ramasubramanian AK. Effect of cold storage on 
shear-induced platelet aggregation and clot strength. The journal of trauma and 
acute care surgery. 2014;77(3 Suppl 2):S88-93. 
22. 
Spinella PC, Holcomb JB. Resuscitation and transfusion principles for traumatic 
hemorrhagic shock. Blood reviews. 2009;23(6):231-240. 

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23. 
Nessen SC, Eastridge BJ, Cronk D, et al. Fresh whole blood use by forward 
surgical teams in Afghanistan is associated with improved survival compared to 
component therapy without platelets. Transfusion. 2013;53 Suppl 1:107s-113s. 
24. 
Spinella PC, Perkins JG, Grathwohl KW, Beekley AC, Holcomb JB. Warm fresh 
whole blood is independently associated with improved survival for patients with 
combat-related traumatic injuries. The Journal of trauma. 2009;66(4 Suppl):S69-
76. 
25. 
Berseus O, Boman K, Nessen SC, Westerberg LA. Risks of hemolysis due to anti-
A and anti-B caused by the transfusion of blood or blood components containing 
ABO-incompatible plasma. Transfusion. 2013;53 Suppl 1:114s-123s. 
26. 
Yazer MH, Jackson B, Sperry JL, Alarcon L, Triulzi DJ, Murdock AD. Initial 
safety and feasibility of cold-stored uncrossmatched whole blood transfusion in 
civilian trauma patients. The journal of trauma and acute care surgery. 
2016;81(1):21-26. 
27. 
Dunbar Nea. Safety of the Use of Thawed Group A Plasma in Trauma. Abstract 
presented at AABB Annual Meeting 2016. 
28. 
Yazer MH, Jackson B, Sperry JL, Alarcon L, Triulzi DJ, Murdock A. Initial 
Safety and Feasibility of Cold Stored Uncrossmatched Whole Blood Transfusion 
in Civilian Trauma Patients. The journal of trauma and acute care surgery. 2016. 
29. 
Gruen RL, Jurkovich GJ, McIntyre LK, Foy HM, Maier RV. Patterns of errors 
contributing to trauma mortality: lessons learned from 2,594 deaths. Annals of 
surgery. 2006;244(3):371-380.