Battlefield Blood Transfusion
CPT James R. Rice, PA-C
Program Manager
Tactical Combat Medical Care
(TCMC)
ReferencesEmergency Medicine: A Comprehensive Study Guide, Tintinalli, 6th ed, Mcgraw-Hill, 2004.
Emergency War Surgery Handbook, 2003, (awaiting publication)
Clinical Laboratory Medicine, Ravel, 6th ed, Mosby, 1995
John B. Holcomb, MD, FACS COL, MC, USA Chief, Trauma Division, Trauma Consultant for The Surgeon General Commander, US Army Institute of Surgical Research
Overview
Compare aspects of the current transfusion approach to the battlefield approach
Discuss the use of PRBC vs. whole blood
Discuss developing a “Walking Blood Bank”
Scenario
You are working at echelon I somewhere in the middle of Iraq when your medics bring you a soldier who was involved in an ambush. He has
taken multiple hits from small arms fire and a RPG.
Scenario
You have evaluated your patient and are attempting to gain control of all the bleeding. You note an altered LOC and an absent radial pulse. vital signs: P-124, B/P-70/P, R-22 and irregular.
Scenario
You start a peripheral IV and give him 500cc if Hetastarch. There is no improvement and even a possible deterioration. There is an enormous dust storm making evacuation impossible.
Now What!!??
Current ATLS Approach
The tenets of shock*
A-establish airway
B-control breathing
C-optimize circulationD-assuring adequate oxygen delivery
E-achieving endpoints of resuscitation
*Tintinalli, pg. 221
Current ATLS Approach
Optimize CirculationControl the hemorrhage
Large bore peripheral IV access
Isotonic crystalloid-NS or LR• Given rapidly (500 or 1000mL)
– then re-evaluate
• Do not over resuscitate
Current ATLS Approach
Optimize CirculationBlood Transfusion*
• No clearly defined parameters to initiate transfusion
• The generally accepted parameter– The patient has only a modest hemodynamic
improvement after 2-3 liters of crystalloid
Get the patient to a surgeon!!* Tintinalli, pg 229
The Combat Environment
Slightly different approach-same goal
Optimize circulation
Get the casualty to a surgeon
The Combat Environment
Optimize circulationHow do we do this?
• Stop the bleeding!• Protect against hypothermia!
The Combat EnvironmentFluid resuscitation algorithm*
Hemodynamically stable-no resuscitationHemodynamically unstable
• Hextend 500ml IV=3 liters of LR– Re-evaluate V/S and mental status
– If stable, STOP– If unstable, repeat:
• Hextend 500ml– Re-evaluate V/S and mental status
– If stable, STOP– If unstable, ????
* Holcomb
The Combat Environment
Triage your supplies and move on to those that can be saved??But what if this is our only casualty?
Can we consider blood transfusion??
The Blood Transfusion Option
Various blood products*
PRBCs
FFP
Platelets
Cryoprecipitate
Albumin
Whole Blood*Clinical Laboratory Medicine
Various blood productsPRBCs
Oxygen carrying capacity
No clotting factor
FFP• No oxygen carrying
capacity• Does have clotting
factor
CryoprecipitateProvides factor VIII
AlbuminVolume expander
Whole BloodProvides oxygen carrying capacity
Provides clotting factors
Provides platelets
Provides volume
Whole Blood
Used for restoration of blood volume due to a loss of plasma and RBCs*1
“Dilutional coagulopathy and hypothermia may be fatal”
Fresh whole blood can be lifesaving*2
*1 Clinical Laboratory Medicine*2 Holcomb (War Surgery)
Battlefield Whole Blood
Fresh whole blood has been successfully used in transfusion since WWI.*
It does have some very significant risksUnsanitary field conditions
Testing of the blood is unavailable
Unreliable donor info-”dog tags” are wrong 2-11% of the time
*Emergency War Surgery Handbook
Battlefield PRBCs
A few considerationsRequires blood banking/lab support
Logistical re-supply
Refrigeration
Golden Hour Container
Keep products cold for 72 hours
Portable
Needs to be re-charged!
Has a NSN
Golden Hour Container3 Color Woodland (Marine Pixel)
NSN: 6530-01-505-5308
Desert PatternNSN: 6530-01-505-5306
3 Color Woodland (Army)NSN: 6530-01-505-5301
Thermal isolation Chamber (Replacement Part)
NSN: 6530-01-505-5311
Battlefield Blood Transfusion
Walking Blood Bank ProgramRequires no blood banking support
Very little lab support needed
Does not require refrigeration
Walking Blood BankPre-screen your unit prior to deployment
Don’t put a lot of trust in “dog tags”
Keep a rosterPersonnel that are co-located with you
• Cooks, mechanics, S-3/S-4 etc…• Provide pre-coordination
Note that almost 50% of the population is type “O”
Walking Blood BankAssemble some extra equipment
Blood collection system• Bag with CPD/tubing/catheter
– Create self contained kits
Filtered “Y” IV tubing• For a filtered infusion of the blood
Specimen kit• Red top tubes
Blood typing kit
Blood Typing Kit (Eldon Card)
Blood Collection Systems
Filtered Administration Set
Walking Blood Bank
The procedureVerify the donor and recipient’s blood type if possible
Clean the donors arm for at least a minute with povidone iodine
Using a blood collection system with CPD, draw off approximately 450cc of whole blood.
Walking Blood Bank
The procedureDraw off additional blood from both the donor and recipientEnsure proper identification of blood
• Place blood specimens in red top tubes and label them appropriately.
• In addition, ensure the donor bag is labeled with the donors information
• Include the blood typing kit– All of the above should be forwarded to the lab
Walking Blood Bank
The procedureConnect the filtered “Y” tubing to a bag of NS and the donor bag.
Start the NS at a TKO rate, then:
Start the blood at a moderate rate
Ensure adequate documentation!
Walking Blood Bank
The procedureShould the patient have an adverse reaction
• Stop the infusion• Initiate benadryl IV (12.5-25mg)• Re-initiate transfusion
Is This Being Done?YES!
I know personally of 3 cases, and there are undoubtedly more out there..
• FST in Afghanistan– Utilized a “walking blood bank” concept
• BAS in Afghanistan– Utilized a “walking blood bank” concept
• FST in Iraq– Utilized a 60cc syringe
• All had good outcomes
Can we do it in a safer manner?
SummaryThe battlefield blood transfusion can potentially buy your patient time to reach a surgeon.
It is a battle proven skill
It should NOT be performed routinely
You should develop a “walking blood bank program” prior to deployment
Questions?
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