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?