03 battlefield blood transfusion

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  • 1. Battlefield Blood Transfusion CPT James R. Rice, PA-C Program Manager Tactical Combat Medical Care (TCMC)
  • 2. References
    • Emergency Medicine: A Comprehensive Study Guide , Tintinalli, 6 th ed, Mcgraw-Hill, 2004.
    • Emergency War Surgery Handbook , 2003, (awaiting publication)
    • Clinical Laboratory Medicine, Ravel, 6 th 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
  • 3. 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”
  • 4. 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.
  • 5. 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.
  • 6. 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!!??
  • 7. Current ATLS Approach
    • The tenets of shock *
      • A-establish airway
      • B-control breathing
      • C-optimize circulation
      • D-assuring adequate oxygen delivery
      • E-achieving endpoints of resuscitation
    • *Tintinalli, pg. 221
  • 8. Current ATLS Approach
    • Optimize Circulation
      • Control the hemorrhage
      • Large bore peripheral IV access
      • Isotonic crystalloid-NS or LR
        • Given rapidly (500 or 1000mL)
          • then re-evaluate
        • Do not over resuscitate
  • 9. Current ATLS Approach
    • Optimize Circulation
      • Blood 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
  • 10. The Combat Environment
    • Slightly different approach-same goal
      • Optimize circulation
      • Get the casualty to a surgeon
  • 11. The Combat Environment
    • Optimize circulation
      • How do we do this?
        • Stop the bleeding!
        • Protect against hypothermia!
  • 12. The Combat Environment
    • Fluid resuscitation algorithm *
      • Hemodynamically stable-no resuscitation
      • Hemodynamically 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
  • 13. 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??
  • 14. The Blood Transfusion Option
    • Various blood products *
      • PRBCs
      • FFP
      • Platelets
      • Cryoprecipitate
      • Albumin
      • Whole Blood
    • *Clinical Laboratory Medicine
  • 15. Various blood products
    • PRBCs
      • Oxygen carrying capacity
      • No clotting factor
    • FFP
        • No oxygen carrying capacity
        • Does have clotting factor
    • Cryoprecipitate
      • Provides factor VIII
    • Albumin
      • Volume expander
    • Whole Blood
      • Provides oxygen carrying capacity
      • Provides clotting factors
      • Provides platelets
      • Provides volume
  • 16. 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)
  • 17. Battlefield Whole Blood
    • Fresh whole blood has been successfully used in transfusion since WWI. *
    • It does have some very significant risks
      • Unsanitary field conditions
      • Testing of the blood is unavailable
      • Unreliable donor info-”dog tags” are wrong 2-11% of the time
    • *Emergency War Surgery Handbook
  • 18. Battlefield PRBCs
    • A few considerations
      • Requires blood banking/lab support
      • Logistical re-supply
      • Refrigeration
  • 19. Golden Hour Container
    • Keep products cold for 72 hours
    • Portable
    • Needs to be re-charged!
    • Has a NSN
  • 20. Golden Hour Container
    • 3 Color Woodland (Marine Pixel)
      • NSN: 6530-01-505-5308
    • Desert Pattern
      • NSN: 6530-01-505-5306
    • 3 Color Woodland (Army)
      • NSN: 6530-01-505-5301
    • Thermal isolation Chamber (Replacement Part)
      • NSN: 6530-01-505-5311
  • 21. Battlefield Blood Transfusion
    • Walking Blood Bank Program
      • Requires no blood banking support
      • Very little lab support needed
      • Does not require refrigeration
  • 22. Walking Blood Bank
    • Pre-screen your unit prior to deployment
      • Don’t put a lot of trust in “dog tags”
    • Keep a roster
      • Personnel 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”
  • 23. Walking Blood Bank
    • Assemble 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
  • 24. Blood Typing Kit (Eldon Card)
  • 25. Blood Collection Systems
  • 26. Filtered Administration Set
  • 27. Walking Blood Bank
    • The procedure
      • Verify 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.
  • 28. Walking Blood Bank
    • The procedure
      • Draw off additional blood from both the donor and recipient
      • Ensure 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
  • 29. Walking Blood Bank
    • The procedure
      • Connect 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!
  • 30. Walking Blood Bank
    • The procedure
      • Should the patient have an adverse reaction
        • Stop the infusion
        • Initiate benadryl IV (12.5-25mg)
        • Re-initiate transfusion
  • 31. 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?
  • 32. Summary
    • The 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
  • 33. Questions?