Battlefield Blood Transfusion CPT James R. Rice, PA-C Program Manager Tactical Combat Medical Care (TCMC)

References Emergency 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* C-optimize circulation A-establish airway B-control breathing C-optimize circulation D-assuring adequate oxygen delivery E-achieving endpoints of resuscitation *Tintinalli, pg. 221

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

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

The Combat Environment Slightly different approach-same goal Optimize circulation Get the casualty to a surgeon

The Combat Environment Optimize circulation How do we do this? Stop the bleeding! Protect against hypothermia!

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 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 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

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 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

Battlefield PRBCs A few considerations Requires 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 Container 3 Color Woodland (Marine Pixel) Desert Pattern 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

Battlefield Blood Transfusion Walking Blood Bank Program Requires no blood banking support Very little lab support needed Does not require refrigeration

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”

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

Blood Typing Kit (Eldon Card)

Blood Collection Systems

Filtered Administration Set

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.

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

Walking Blood Bank The procedure Ensure adequate documentation! 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!

Walking Blood Bank The procedure Should the patient have an adverse reaction Stop the infusion Initiate benadryl IV (12.5-25mg) Re-initiate transfusion

Is This Being Done? YES! Can we do it in a safer manner? 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 FST in Iraq Utilized a 60cc syringe All had good outcomes Can we do it in a safer manner?

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

Questions?