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, 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

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* 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

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
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) Desert Pattern
NSN:
Desert Pattern
NSN:
3 Color Woodland (Army)
NSN:
Thermal isolation Chamber (Replacement Part)
NSN:

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 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!

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

31. 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?

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?