03 battlefield blood transfusion


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03 battlefield blood transfusion

  1. 1. Battlefield Blood Transfusion CPT James R. Rice, PA-C Program Manager Tactical Combat Medical Care (TCMC)
  2. 2. References <ul><li>Emergency Medicine: A Comprehensive Study Guide , Tintinalli, 6 th ed, Mcgraw-Hill, 2004. </li></ul><ul><li>Emergency War Surgery Handbook , 2003, (awaiting publication) </li></ul><ul><li>Clinical Laboratory Medicine, Ravel, 6 th ed, Mosby, 1995 </li></ul><ul><li>John B. Holcomb, MD, FACS COL, MC, USA Chief, Trauma Division, Trauma Consultant for The Surgeon General Commander, US Army Institute of Surgical Research </li></ul>
  3. 3. Overview <ul><li>Compare aspects of the current transfusion approach to the battlefield approach </li></ul><ul><li>Discuss the use of PRBC vs. whole blood </li></ul><ul><li>Discuss developing a “Walking Blood Bank” </li></ul>
  4. 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. 5. Scenario <ul><li>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. </li></ul>
  6. 6. Scenario <ul><li>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. </li></ul><ul><li>Now What!!?? </li></ul>
  7. 7. Current ATLS Approach <ul><li>The tenets of shock * </li></ul><ul><ul><li>A-establish airway </li></ul></ul><ul><ul><li>B-control breathing </li></ul></ul><ul><ul><li>C-optimize circulation </li></ul></ul><ul><ul><li>D-assuring adequate oxygen delivery </li></ul></ul><ul><ul><li>E-achieving endpoints of resuscitation </li></ul></ul><ul><li>*Tintinalli, pg. 221 </li></ul>
  8. 8. Current ATLS Approach <ul><li>Optimize Circulation </li></ul><ul><ul><li>Control the hemorrhage </li></ul></ul><ul><ul><li>Large bore peripheral IV access </li></ul></ul><ul><ul><li>Isotonic crystalloid-NS or LR </li></ul></ul><ul><ul><ul><li>Given rapidly (500 or 1000mL) </li></ul></ul></ul><ul><ul><ul><ul><li>then re-evaluate </li></ul></ul></ul></ul><ul><ul><ul><li>Do not over resuscitate </li></ul></ul></ul>
  9. 9. Current ATLS Approach <ul><li>Optimize Circulation </li></ul><ul><ul><li>Blood Transfusion * </li></ul></ul><ul><ul><ul><li>No clearly defined parameters to initiate transfusion </li></ul></ul></ul><ul><ul><ul><li>The generally accepted parameter </li></ul></ul></ul><ul><ul><ul><ul><li>The patient has only a modest hemodynamic improvement after 2-3 liters of crystalloid </li></ul></ul></ul></ul><ul><li>Get the patient to a surgeon!! </li></ul><ul><li>* Tintinalli, pg 229 </li></ul>
  10. 10. The Combat Environment <ul><li>Slightly different approach-same goal </li></ul><ul><ul><li>Optimize circulation </li></ul></ul><ul><ul><li>Get the casualty to a surgeon </li></ul></ul>
  11. 11. The Combat Environment <ul><li>Optimize circulation </li></ul><ul><ul><li>How do we do this? </li></ul></ul><ul><ul><ul><li>Stop the bleeding! </li></ul></ul></ul><ul><ul><ul><li>Protect against hypothermia! </li></ul></ul></ul>
  12. 12. The Combat Environment <ul><li>Fluid resuscitation algorithm * </li></ul><ul><ul><li>Hemodynamically stable-no resuscitation </li></ul></ul><ul><ul><li>Hemodynamically unstable </li></ul></ul><ul><ul><ul><li>Hextend 500ml IV=3 liters of LR </li></ul></ul></ul><ul><ul><ul><ul><li>Re-evaluate V/S and mental status </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>If stable, STOP </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>If unstable, repeat: </li></ul></ul></ul></ul></ul><ul><ul><ul><li>Hextend 500ml </li></ul></ul></ul><ul><ul><ul><ul><li>Re-evaluate V/S and mental status </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>If stable, STOP </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>If unstable, ???? </li></ul></ul></ul></ul></ul><ul><li>* Holcomb </li></ul>
  13. 13. The Combat Environment <ul><li>Triage your supplies and move on to those that can be saved?? </li></ul><ul><li>But what if this is our only casualty? </li></ul><ul><li>Can we consider blood transfusion?? </li></ul>
  14. 14. The Blood Transfusion Option <ul><li>Various blood products * </li></ul><ul><ul><li>PRBCs </li></ul></ul><ul><ul><li>FFP </li></ul></ul><ul><ul><li>Platelets </li></ul></ul><ul><ul><li>Cryoprecipitate </li></ul></ul><ul><ul><li>Albumin </li></ul></ul><ul><ul><li>Whole Blood </li></ul></ul><ul><li>*Clinical Laboratory Medicine </li></ul>
  15. 15. Various blood products <ul><li>PRBCs </li></ul><ul><ul><li>Oxygen carrying capacity </li></ul></ul><ul><ul><li>No clotting factor </li></ul></ul><ul><li>FFP </li></ul><ul><ul><ul><li>No oxygen carrying capacity </li></ul></ul></ul><ul><ul><ul><li>Does have clotting factor </li></ul></ul></ul><ul><li>Cryoprecipitate </li></ul><ul><ul><li>Provides factor VIII </li></ul></ul><ul><li>Albumin </li></ul><ul><ul><li>Volume expander </li></ul></ul><ul><li>Whole Blood </li></ul><ul><ul><li>Provides oxygen carrying capacity </li></ul></ul><ul><ul><li>Provides clotting factors </li></ul></ul><ul><ul><li>Provides platelets </li></ul></ul><ul><ul><li>Provides volume </li></ul></ul>
  16. 16. Whole Blood <ul><li>Used for restoration of blood volume due to a loss of plasma and RBCs *1 </li></ul><ul><li>“ Dilutional coagulopathy and hypothermia may be fatal” </li></ul><ul><ul><li>Fresh whole blood can be lifesaving *2 </li></ul></ul><ul><li>*1 Clinical Laboratory Medicine </li></ul><ul><li>*2 Holcomb (War Surgery) </li></ul>
  17. 17. Battlefield Whole Blood <ul><li>Fresh whole blood has been successfully used in transfusion since WWI. * </li></ul><ul><li>It does have some very significant risks </li></ul><ul><ul><li>Unsanitary field conditions </li></ul></ul><ul><ul><li>Testing of the blood is unavailable </li></ul></ul><ul><ul><li>Unreliable donor info-”dog tags” are wrong 2-11% of the time </li></ul></ul><ul><li>*Emergency War Surgery Handbook </li></ul>
  18. 18. Battlefield PRBCs <ul><li>A few considerations </li></ul><ul><ul><li>Requires blood banking/lab support </li></ul></ul><ul><ul><li>Logistical re-supply </li></ul></ul><ul><ul><li>Refrigeration </li></ul></ul>
  19. 19. Golden Hour Container <ul><li>Keep products cold for 72 hours </li></ul><ul><li>Portable </li></ul><ul><li>Needs to be re-charged! </li></ul><ul><li>Has a NSN </li></ul>
  20. 20. Golden Hour Container <ul><li>3 Color Woodland (Marine Pixel) </li></ul><ul><ul><li>NSN: 6530-01-505-5308 </li></ul></ul><ul><li>Desert Pattern </li></ul><ul><ul><li>NSN: 6530-01-505-5306 </li></ul></ul><ul><li>3 Color Woodland (Army) </li></ul><ul><ul><li>NSN: 6530-01-505-5301 </li></ul></ul><ul><li>Thermal isolation Chamber (Replacement Part) </li></ul><ul><ul><li>NSN: 6530-01-505-5311 </li></ul></ul>
  21. 21. Battlefield Blood Transfusion <ul><li>Walking Blood Bank Program </li></ul><ul><ul><li>Requires no blood banking support </li></ul></ul><ul><ul><li>Very little lab support needed </li></ul></ul><ul><ul><li>Does not require refrigeration </li></ul></ul>
  22. 22. Walking Blood Bank <ul><li>Pre-screen your unit prior to deployment </li></ul><ul><ul><li>Don’t put a lot of trust in “dog tags” </li></ul></ul><ul><li>Keep a roster </li></ul><ul><ul><li>Personnel that are co-located with you </li></ul></ul><ul><ul><ul><li>Cooks, mechanics, S-3/S-4 etc… </li></ul></ul></ul><ul><ul><ul><li>Provide pre-coordination </li></ul></ul></ul><ul><ul><li>Note that almost 50% of the population is type “O” </li></ul></ul>
  23. 23. Walking Blood Bank <ul><li>Assemble some extra equipment </li></ul><ul><ul><li>Blood collection system </li></ul></ul><ul><ul><ul><li>Bag with CPD/tubing/catheter </li></ul></ul></ul><ul><ul><ul><ul><li>Create self contained kits </li></ul></ul></ul></ul><ul><ul><li>Filtered “Y” IV tubing </li></ul></ul><ul><ul><ul><li>For a filtered infusion of the blood </li></ul></ul></ul><ul><ul><li>Specimen kit </li></ul></ul><ul><ul><ul><li>Red top tubes </li></ul></ul></ul><ul><ul><li>Blood typing kit </li></ul></ul>
  24. 24. Blood Typing Kit (Eldon Card)
  25. 25. Blood Collection Systems
  26. 26. Filtered Administration Set
  27. 27. Walking Blood Bank <ul><li>The procedure </li></ul><ul><ul><li>Verify the donor and recipient’s blood type if possible </li></ul></ul><ul><ul><li>Clean the donors arm for at least a minute with povidone iodine </li></ul></ul><ul><ul><li>Using a blood collection system with CPD, draw off approximately 450cc of whole blood. </li></ul></ul>
  28. 28. Walking Blood Bank <ul><li>The procedure </li></ul><ul><ul><li>Draw off additional blood from both the donor and recipient </li></ul></ul><ul><ul><li>Ensure proper identification of blood </li></ul></ul><ul><ul><ul><li>Place blood specimens in red top tubes and label them appropriately. </li></ul></ul></ul><ul><ul><ul><li>In addition, ensure the donor bag is labeled with the donors information </li></ul></ul></ul><ul><ul><ul><li>Include the blood typing kit </li></ul></ul></ul><ul><ul><ul><ul><li>All of the above should be forwarded to the lab </li></ul></ul></ul></ul>
  29. 29. Walking Blood Bank <ul><li>The procedure </li></ul><ul><ul><li>Connect the filtered “Y” tubing to a bag of NS and the donor bag. </li></ul></ul><ul><ul><li>Start the NS at a TKO rate, then: </li></ul></ul><ul><ul><li>Start the blood at a moderate rate </li></ul></ul><ul><ul><li>Ensure adequate documentation! </li></ul></ul>
  30. 30. Walking Blood Bank <ul><li>The procedure </li></ul><ul><ul><li>Should the patient have an adverse reaction </li></ul></ul><ul><ul><ul><li>Stop the infusion </li></ul></ul></ul><ul><ul><ul><li>Initiate benadryl IV (12.5-25mg) </li></ul></ul></ul><ul><ul><ul><li>Re-initiate transfusion </li></ul></ul></ul>
  31. 31. Is This Being Done? <ul><li>YES! </li></ul><ul><ul><li>I know personally of 3 cases, and there are undoubtedly more out there.. </li></ul></ul><ul><ul><ul><li>FST in Afghanistan </li></ul></ul></ul><ul><ul><ul><ul><li>Utilized a “walking blood bank” concept </li></ul></ul></ul></ul><ul><ul><ul><li>BAS in Afghanistan </li></ul></ul></ul><ul><ul><ul><ul><li>Utilized a “walking blood bank” concept </li></ul></ul></ul></ul><ul><ul><ul><li>FST in Iraq </li></ul></ul></ul><ul><ul><ul><ul><li>Utilized a 60cc syringe </li></ul></ul></ul></ul><ul><ul><ul><li>All had good outcomes </li></ul></ul></ul><ul><li>Can we do it in a safer manner? </li></ul>
  32. 32. Summary <ul><li>The battlefield blood transfusion can potentially buy your patient time to reach a surgeon. </li></ul><ul><li>It is a battle proven skill </li></ul><ul><li>It should NOT be performed routinely </li></ul><ul><li>You should develop a “walking blood bank program” prior to deployment </li></ul>
  33. 33. Questions?