Battlefield Blood Transfusion

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*
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
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 products

PRBCs
Oxygen carrying capacity No clotting factor

Albumin
Volume expander

Whole Blood
Provides oxygen carrying capacity Provides clotting factors Provides platelets Provides volume

FFP
No oxygen carrying capacity Does have clotting factor

Cryoprecipitate
Provides factor VIII

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 211% 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 recharged! Has a NSN

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

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
Dont 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 recipients 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
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!
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?

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?