# Direct blood transfusion



## kaja (Jan 25, 2011)

Hi guys

I read somewhere, that some SF 18D carry sets for direct blood  transfusion in field. From my point of view, it looks like really good  idea, since only blood can carry oxygen, and if you have few more guys  on group with same blood type (or O neg .....) and there is minimal risk of their injury (like long firefight, IED hazard,...) they should tolerate donation of few hundred ml. IIRC, the set contained  bag for blood with anti-coagulant , some tubing, cross-test and  transfusion sets... Do you have any experience/ info on that?

 Thanks

 Kaja


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## TLDR20 (Jan 25, 2011)

It is something that is possible, but I honestly would not be super comfortable with it. It is not in my aidbag and you have now effectively taken two guys out of the fight, also should there be a reaction your problems have gone from bad to much much worse in mins.


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## Ranger Psych (Jan 25, 2011)

Direct blood transfusion regardless of simple type match, is a really, really, really, really, bad idea.


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## pardus (Jan 25, 2011)

Real, fresh, blood is the best thing you can give someone with blood loss. Sooner the better.
That said I'm not sure I'd be real comfortable doing a direct transfusion in the field unless it was under a certain set of circumstances.

It's not an option at my level anyway so it's a moot point for me.


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## policemedic (Jan 25, 2011)

I agree with all the above.  Can it be done? Sure.  The real question is one of risk vs. benefits and you have to take medical issues and tactical issues into account. Blood products should never be given blithely and without preparation for a SHTF scenario.  In any case, there are better and safer options in use by other nation's SOF medics.


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## Muppet (Jan 25, 2011)

Well, not an 18D but if you have a hemolytic reaction to the blood, well that can be really bad. Other volume expanders can benefit in the short term (hetastartch). Anybody using that stuff?

F.M.


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## pardus (Jan 25, 2011)

Firemedic said:


> Well, not an 18D but if you have a hemolytic reaction to the blood, well that can be really bad. Other volume expanders can benefit in the short term (hetastartch). Anybody using that stuff?
> 
> F.M.



We lost hetastartch. Too many retard CLS guys giving it to people who were dehydrated... yeah....
Loosing LRS as well, it's all saline now for us.


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## Muppet (Jan 25, 2011)

That sucks bro. Nothing like giving saline to the point of breaking clots and making cool aid. :) I say retrain the folks but, hell that would make sense.

F.M.


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## pardus (Jan 25, 2011)

Yeah, like that other thread I posted said, being a little dry is preferable to kool aid, so hold off on the fluids if you can.

http://www.shadowspear.com/vb/threa...chniques-to-save-wounded-in-afghanistan.8835/


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## Muppet (Jan 25, 2011)

You be correct my good man. Permissive hypotension is our friend. :)

F.M.


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## Diamondback 2/2 (Jan 25, 2011)

pardus said:


> We lost hetastartch. *Too many retard CLS guys giving it to people who were dehydrated*... yeah....
> Loosing LRS as well, it's all saline now for us.


 
LOL I have seen it happen!!! Not cool.


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## surgicalcric (Jan 25, 2011)

You guys are missing the point entirely.

It is not for times when the evac times are short -within reason; it is for times like the beginning of the Afghan invasion where the closest MH-47 was a 4 hour flight to the casualty.  It came to be after several guys died who could have possibly benefited from receiving whole blood in the field.  I say possibly because the guys died before getting to a MTF of non-compressible hemorrhage and it isn't known whether they would have lived or not had they received the transfusion.  Shortly therafter a forward thinking Group Surgeon proposed the idea and it was widely adopted.

Furthermore, while permissive hypotension (PHPTN) is a good thing when there isnt a better option a patient can only be sustained in the field this way for a very finite amount of time.  This time varies from patient to patient in the field and is based on a wide number of conditions from hydration level prior to insult to the ability of the medic to maintain the patients core temp greater than 96 degrees.

As for typing, I know all of my guys types - even the attachments to my team; it is stamped on their dogtags and is printed by me on their FCC's.  That is the least of my concerns... Is it something I want to do, no.  It is a procedure I am prepared to do though



Firemedic said:


> ...if you have a hemolytic reaction to the blood, well that can be really *bad*...



So can dying from hypovolemic shock.


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## Muppet (Jan 25, 2011)

surgicalcric said:


> You guys are missing the point entirely.
> 
> It is not for times when the evac times are short -within reason; it is for times like the beginning of the Afghan invasion where the closest MH-47 was a 4 hour flight to the casualty. It came to be after several guys died who could have possibly benefited from receiving whole blood in the field. I say possibly because the guys died before getting to a MTF of non-compressible hemorrhage and it isn't known whether they would have lived or not had they received the transfusion. Shortly therafter a forward thinking Group Surgeon proposed the idea and it was widely adopted.
> 
> ...




I see your point Surgicalcric and once again, I learned something and I appreciate that brother.

F.M.


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## TLDR20 (Jan 25, 2011)

surgicalcric said:


> You guys are missing the point entirely.
> It is not for times when the evac times are short -within reason; it is for times like the beginning of the Afghan invasion where the closest MH-47 was a 4 hour flight to the casualty.  It came to be after several guys died who could have possibly benefited from receiving whole blood in the field.  I say possibly because the guys died before getting to a MTF of non-compressible hemorrhage and it isn't known whether they would have lived or not had they received the transfusion.  Shortly therafter a forward thinking Group Surgeon proposed the idea and it was widely adopted.
> 
> Furthermore, while permissive hypotension (PHPTN) is a good thing when there isnt a better option a patient can only be sustained in the field this way for a very finite amount of time.  This time varies from patient to patient in the field and is based on a wide number of conditions from hydration level prior to insult to the ability of the medic to maintain the patients core temp greater than 96 degrees.
> . Is it something I want to do, no.  It is a procedure I am prepared to do though



I agree with everything said, the highlighted portion especially, most young/less trained medics forget this part of their TCCC and ACLS codes. The blood transfusion is something I can do, and will do to save a life, I don't want to portray otherwise.

As for the permissive hypotension, it is gaining a lot of traction in the Pre-hospital setting. However if it is my buddy I am prolly going to go ahead and give him the hetastarch.


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## surgicalcric (Jan 25, 2011)

cback0220 said:


> ...As for the permissive hypotension, it is gaining a lot of traction in the Pre-hospital setting...



And I am glad to see it...

Having been a paramedic for 14 years prior to going to the SFQC I have seen far too many paramedics/EMT-Is, who could/can only treat patients according to an algorithm with no thought to or idea about what is actually going on at the cellular level in a patient, bring trauma patients in leaking raspberry cool-aid, with their standard (2) 14-16 ga caths running NS or LR WAO (Wide Assed Open.)  This is unsat for a myriad of reasons too lengthy to discuss here.  Suffice to say hem-control must be gained, in those with *compressible* bleeds, before fluid resuscitation should be a consideration.  It is also good to see civilian EMS/Emer Med picking up on our lessons learned.

I am a big supporter of PHPTN and utilize it to the fullest but I know it has a point of diminishing return(s) and prepare accordingly, as I know you do.

Crip


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## pardus (Jan 25, 2011)

surgicalcric said:


> It is not for times when the evac times are short -within reason; it is for times like the beginning of the Afghan invasion where the closest MH-47 was a 4 hour flight to the casualty.  It came to be after several guys died who could have possibly benefited from receiving whole blood in the field.  I say possibly because the guys died before getting to a MTF of non-compressible hemorrhage and it isn't known whether they would have lived or not had they received the transfusion.  Shortly therafter a forward thinking Group Surgeon proposed the idea and it was widely adopted.
> 
> Furthermore, while permissive hypotension (PHPTN) is a good thing when there isnt a better option a patient can only be sustained in the field this way for a very finite amount of time.  This time varies from patient to patient in the field and is based on a wide number of conditions from hydration level prior to insult to the ability of the medic to maintain the patients core temp greater than 96 degrees.
> 
> As for typing, I know all of my guys types - even the attachments to my team; it is stamped on their dogtags and is printed by me on their FCC's.  That is the least of my concerns... Is it something I want to do, no.  It is a procedure I am prepared to do though



Agreed 100%

(who the fuck am I to disagree anyway? lol)


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## x SF med (Jan 26, 2011)

Crip-
Do you do pre-mission titering for reactive proteins for the entire team so you know who can't take the same type blood?  It's not a perfect system, but it could keep guys alive when you have to go the direct transusion route without the ability to spin down and filter the blood to plasma, packed cells and garbage.


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## surgicalcric (Jan 26, 2011)

x SF med said:


> Crip-
> Do you do pre-mission titering for reactive proteins for the entire team so you know who can't take the same type blood?  It's not a perfect system, but it could keep guys alive when you have to go the direct transusion route without the ability to spin down and filter the blood to plasma, packed cells and garbage.



P:

I have had them done in the past but don't do them prior to every rotation.  I had the idea sold to our Group Surgeon at one time -because someone has to pay for the titers right...- but there has been a change in the Med Section and our current Group SGN isn't the person we need in that position.  I have recently been pushing buttons again and am hoping to make some head way on the topic -as well as a few others which I believe are important in planning for sustained operations where med support comes from my aidbag and not a CSH or FST down the road by air...

That is another topic for another time though...


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## policemedic (Jan 26, 2011)

pardus said:


> We lost hetastartch. Too many retard CLS guys giving it to people who were dehydrated... yeah....
> Loosing LRS as well, it's all saline now for us.



Yet more proof of why the CLS program overreaches it's capability to train people to competency.  I routinely removed Hextend from the CLS bags because none of my CLS trained soldiers understood how it worked.


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## policemedic (Jan 26, 2011)

surgicalcric said:


> You guys are missing the point entirely.
> 
> It is not for times when the evac times are short -within reason; it is for times like the beginning of the Afghan invasion where the closest MH-47 was a 4 hour flight to the casualty. It came to be after several guys died who could have possibly benefited from receiving whole blood in the field. I say possibly because the guys died before getting to a MTF of non-compressible hemorrhage and it isn't known whether they would have lived or not had they received the transfusion. Shortly therafter a forward thinking Group Surgeon proposed the idea and it was widely adopted.
> 
> ...



These are all good points, and I don't disagree.  I just think we need to push for the approval of treatment options like lyophilized plasma, such as French SOF have available (and which some injured US troops have received).


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## Diamondback 2/2 (Jan 26, 2011)

policemedic said:


> Yet more proof of why the CLS program overreaches it's capability to train people to competency. I routinely removed Hextend from the CLS bags because none of my CLS trained soldiers understood how it worked.



If I am not mistaken, they pulled IV theropy from the CLS course and removed it from all the bags. Personally I think it should be in the bag and trained on, but only when a medic say's yay or nay. I have used Hextend on a few multi-amputees in the past, I always had my bags marked with red/blue tape and Hex was always red. I don't know enough about anything med to do much but basic life support stuff, but I can open/make an airway, I can stop most bleeds and I can fix up a hang over
	

	
	
		
		

		
			





....But yeah I agree with all of you on this stuff, I think they should just expand on the CLS course (mainly b/c there is never enough medics when shit gets fucked).

As for the thread I am simply in awww of you 18D's, I wish we had medics like you dudes in line companies. Most of the medics I have had in the past did not give me that much of a good feeling of "going to be properly taken care of" when shit gets fucked.


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## 8'Duece (Jan 26, 2011)

x SF med said:


> Crip-
> Do you do pre-mission titering for reactive proteins for the entire team so you know who can't take the same type blood? It's not a perfect system, but it could keep guys alive when you have to go the direct transusion route without the ability to spin down and filter the blood to plasma, packed cells and garbage.



Never thought about this but as I learn more and more I'm wondering what anti-bodies you would test for ?  MMR ? Hep B ? Hep C  Hep A, other anti-bodies ???

Remember, I'm not in a clinical phase yet.


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## surgicalcric (Jan 26, 2011)

policemedic said:


> ...we need to push for the approval of treatment options like lyophilized plasma...



It is being actively pursued as well as a couple other options.  However in the interim -and as a SOCM instructor of mine was fond of saying- you got what you got and you treat the patient with what you have, not what you would like to have.

Crip


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## x SF med (Jan 26, 2011)

surgicalcric said:


> P:
> 
> I have had them done in the past but don't do them prior to every rotation. I had the idea sold to our Group Surgeon at one time -because someone has to pay for the titers right...- but there has been a change in the Med Section and our current Group SGN isn't the person we need in that position. I have recently been pushing buttons again and am hoping to make some head way on the topic -as well as a few others which I believe are important in planning for sustained operations where med support comes from my aidbag and not a CSH or FST down the road by air...
> 
> That is another topic for another time though...



Titers can change over time based on hydration, exposure to new infectors, actually having had an infection, surgery, exposure to allergens, and changes in the innoculation schedule...   Primum Non Nocere says you need to know in order to reduce the chance of creating a bigger problem than you already have.  A small cost for titering and reactive profiles for Teammates is much lower than replacing even one Teammate.  Penny wise, pound foolish.


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## Headshot (Jan 26, 2011)

For some reason I remember hearing (may be rumor) that LTC Iceal Hambleton had been shot or had several wounds  during his SERE in Vietnam and it wasn't until they stuck him that he started to bleed heavily.  The dehydration helped save his life is the point.  Anyone else hear this, I can't find anything in his bio about it.


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## Manolito (Jan 26, 2011)

The capabilites of today and the training of the medics today are beyond my comprehension. Back when the earth was still cooling BLS (Basic Life Support) was the treatment of the day. Some days you got a Doc that was on his game and you felt pretty good. Other times not so good.
To those that have gone before you and to those to follow Thank You for what you do.
Respectfully,
Bill


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## surgicalcric (Jan 26, 2011)

x SF med said:


> Titers can change over time...
> 
> A small cost for titering and reactive profiles for Teammates is much lower than replacing even one Teammate.  Penny wise, pound foolish.



I am in total agreement but unfortunately -for my guys- the SGN outranks me...


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## TLDR20 (Jan 27, 2011)

surgicalcric said:


> It is being actively pursued as well as a couple other options.  However in the interim -and as a SOCM instructor of mine was fond of saying- you got what you got and you treat the patient with what you have, not what you would like to have.
> 
> Crip



I actually have a pretty good story about that. My pre-test in CTM, I am all stressed out and amped up as you can be, The night before I meticulously packed my bag, went over it 10 times. Well come pre test day and sure enough I forgot to re-tape my tape board, and had forgotten tape. I ran my whole clinic wit maybe 5 pieces of tape. Surgicalcric I am sure you understand how bad that sucked. I would have passed the clinic however it took me a while to figure out exotic ways to tape my procedures down. Learned a huge lesson there though. From then on I have always made a checklist and packed off of that. Because you will always have what you have, not what you wished you had.

Passed on the test day with a 13:00 min initial and rapid, and more tape then I knew what to do with :cool:


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## surgicalcric (Jan 27, 2011)

[Sidebar]



cback0220 said:


> ...Surgicalcric I am sure you understand how bad that sucked...



Brother I know...

My trouble didn't come in the form of tape but with my BVM.  As you know there is really not a good place to carry that damn thing on or in the old M5 bags they issued us so I came up with the idea of placing a small snaplink -like the ones used for keys- on the strap of the BVM and attaching it to the 550 cord on the balsawood splint contraption THE NIGHT BEFORE the pretest.  Needless to say this wasnt the most intelligent of ideas but the good idea fairy had taken control.

Fast forward to the next morning...  I am standing along side the rest of the guys in the first iteration when "MEDIC" is yelled.  We all take off in a dead sprint for our specific cadre.  I arrive at my patient with Sadiki (another student who is the assistant) to find a blast injured patient...  The initial went fine: TQs, occlusives, NPA, stump dressing in place, and patient moved to poleless (Polish) litter and to a halt.  Once behind "cover" previous treatments were checked, with the patients breathing becoming labored so I needle-D him and grab for my BVM only to find the 550 cord had teared thru the 100mph tape and my BVM was GONE...  I can only imagine the look of fear on my face at my recent discovery.  The cadre was talking with another cadre and not really paying as close attention as he should have -thank God- when another pair of students with their patient sundered by, dropping the BVM at my right knee; opposite my M5 and out of sight of the cadre.  The rest of my run went very well...

I learned later that it was when I jumped the ditch at the fence that the BVM fell off.

I have a list of funny stories from SOCM/SFMS that I may put to pen one day...  Good Times indeed!

Crip


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## pardus (Jan 27, 2011)

I hope you brought those students a beer or two Crip, good save!


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## Headshot (Jan 27, 2011)

Just noticed this thread has alot of Crip and bloods on here.   Gangsta out!

In all seriousness though, good thread!  This is one of those read and learn that make this site worth its salt.


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## surgicalcric (Jan 27, 2011)

pardus said:


> I hope you brought those students a beer or two...



Nope, a bottle of Johnny Walker Black Label for one and Jim Beam for the other.  ;)

Crip


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## surgicalcric (Jan 27, 2011)

Headshot said:


> Just noticed this thread has alot of Crip and bloods on here.   Gangsta out!



Good catch on the gang reference; didnt even notice.


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## TLDR20 (Jan 27, 2011)

surgicalcric said:


> [Sidebar]
> I have a list of funny stories from SOCM/SFMS that I may put to pen one day...  Good Times indeed!
> 
> Crip



Yeah I do too, the look of fear in everyones eyes on cath/npa/oral gastric tube day was pretty funny. 45 stone cold killers in a circle throwing up and tearing up like a babies is a pretty funny sight!


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## Red Flag 1 (Jan 27, 2011)

"I am a big supporter of PHPTN and utilize it to the fullest but I know it has a point of diminishing return(s) and prepare accordingly, as I know you do."

Have used this in surgery, deliberate controlled hypotensive anesthesia. Deliberately lowering blood pressure during surgery will reduce operative blood loss. Using this technique requires direct arterial pressure monitoring, and a careful pre-op workup; not all patients are candidates for this...........


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## Medicine-Man (Jan 27, 2011)

Mmmm...Good thread. ;)


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## pardus (Jan 27, 2011)

Headshot said:


> Just noticed this thread has alot of Crip and bloods on here.   Gangsta out!
> 
> In all seriousness though, good thread!  This is one of those read and learn that make this site worth its salt.



This is a site that confirms what a wanker you are and what an uneducated newb I am to medicine...


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## Muppet (Jan 27, 2011)

HEY! Do we get C.M.E.'s for this? :)

F.M.


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## Muppet (Jan 27, 2011)

pardus said:


> This is a site that confirms what a wanker you are and what an uneducated newb I am to medicine...



Uneducated newb. is not the word to use. You are more than capable to do your job and this site just adds to your tool box of skills. :)

F.M.


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## TLDR20 (Jan 27, 2011)

pardus said:


> This is a site that confirms what a wanker you are and what an uneducated newb I am to medicine...



The best part of medicine is that you are always new to something, and there is always more to learn. Same goes for every job in the military. You can always improve upon your skillset.


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## x SF med (Jan 27, 2011)

cback0220 said:


> Yeah I do too, the look of fear in everyones eyes on cath/npa/oral gastric tube day was pretty funny. 45 stone cold killers in a circle throwing up and tearing up like a babies is a pretty funny sight!



Finger wave day was fun too...  NOT.


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## surgicalcric (Jan 28, 2011)

cback0220 said:


> The best part of medicine is that you are always new to something, and there is always more to learn... You can always improve upon your skillset.



I couldn't have said it better myself.

The lives of those around us and those we come in contact with demand that we learn something everyday we practice medicine.

Back when I was working at the FD (it seems so long ago now) I put a sign on every bathroom mirror -at eye level- in every station in the city.  It read, "does the person you see instill confidence in you that he could save your life."  That pause for introspection was passed to me by a firefighter/paramedic instructor in the academy in 1990; it rings as true in my soul today as it did then.

The day I fail to answer yes is the day I hang up my aidbag.

Crip


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## Muppet (Jan 28, 2011)

surgicalcric said:


> I couldn't have said it better myself.
> 
> The lives of those around us and those we come in contact with demand that we learn something everyday we practice medicine.
> 
> ...




My old Batt. P.A. / 18D himself once told me" If I study 1/2 hour a day on my profession (being medical) I will be in the top 5% of my profession". I still use that when I teach A.L.S. / B.L.S. classes to my peers. Thanks for that saying / you mind if I quote that (from a friend)?

F.M.


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## surgicalcric (Jan 28, 2011)

Firemedic said:


> ...Thanks for that saying / you mind if I quote that (from a friend)?



I dont mind at all...

Okay folks...I would like to keep this thread alive.

SOOO, since we (in the US) don't have other options available for replacing RBC's in the field I would like to hear what some of you believe should be the criteria to begin the procedure.  After a few of you have added your ideas I will post the SOCOM SGN's directives regarding such.

Crip


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## The91Bravo (Jan 28, 2011)

Forgive the ignorance, but I left the Army and combat medicine in 1997, what is Hetastartch, and what are it's indications?

Thanks
S

ETA:  And Hextend??

As for 'instilling confidence'  I remember when we were in Panama doing the Jungle Warfare training cycle, and one of my guys found some embedded concertina wire hidden in the brush he was hauling ass through (during the live fire with 80mm danger close)  Anyway, he finishes his lane then I hear they need a medic, I turn around and this Joe is laid out.  Not only with many lower leg lacerations, but he does not like the sight of blood.  I start to treat him when he comes around... He looks up at me and says "Phew.  I am glad it's you Doc, and not Villarreal"  
	

	
	
		
		

		
			





 (our brand new junior medic who had never been to the field yet)

It was a good feeling.


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## policemedic (Jan 29, 2011)

The91Bravo said:


> Forgive the ignorance, but I left the Army and combat medicine in 1997, what is Hetastartch, and what are it's indications?
> 
> Thanks
> S
> ...



Hextend is a trade name for an artificial colloid plasma expanding solution containing 6% hetastarch in a solution that more closely resembles plasma than LR/NS does. Hetastarch itself is an artificial colloid molecule. Hextend has lactate, dextrose, and 'lytes (sodium, K+, mag, calcium, and chloride). It is indicated for plasma expansion secondary to blood loss, and works primarily by creating an oncotic gradient. As such, it remains in the intravascular space longer than crystalloids, and demonstrates an increase in intravascular volume that is out of proportion to the amount administered (the Army says a 500cc bag of Hextend provides an 800cc increase in volume).

The benefits of Hextend vs other colloids are that unlike 5% albumin, there is no chance of transmitting a virus or other nastiness to the pt, and compared to 6% hetastarch in saline (HES) the odds of creating coagulation or 'lyte issues are virtually nil. That's not to say it's perfect; the odds of renal problems and anaphylaxis are higher compared to albumin.

There is obviously a great weight advantage here. It's easier to carry 500cc bags than liter bags. It's also easier for people trained at the CLS level to make a mistake with.



The91Bravo said:


> As for 'instilling confidence' I remember when we were in Panama doing the Jungle Warfare training cycle, and one of my guys found some embedded concertina wire hidden in the brush he was hauling ass through (during the live fire with 80mm danger close) Anyway, he finishes his lane then I hear they need a medic, I turn around and this Joe is laid out. Not only with many lower leg lacerations, but he does not like the sight of blood. I start to treat him when he comes around... He looks up at me and says "Phew. I am glad it's you Doc, and not Villarreal" :) (our brand new junior medic who had never been to the field yet)
> 
> It was a good feeling.



That must have put a smile on your face!


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## Purple (Jan 29, 2011)

Our old SOP had every man carrying a can of HSA and a transfusion set - we later replaced the HSA with 500ml of LRS - in SF what you have can often be all you have and all you are going to get for quite awhile.  It is what it is.

Purple


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## x SF med (Jan 29, 2011)

surgicalcric said:


> I dont mind at all...
> 
> Okay folks...I would like to keep this thread alive.
> 
> ...



  Rocky was my primary instructor for the "300-F-1 and Clinical rotations" when he was a CPT.  He is an SF Medic at heart, no matter how many medical degrees and affiliations he has.  I have a feeling his directive(s) are pretty close to:

"You are the best trained medics in the world, you are responsible to your teammates for their health and making sure they come home if at all possible - use your initiative, your brains, your local resources to protect your Brothers, use your Brothers to keep anoher alive if the situation allows.  Primum non Nocere is your key objective.  Do what it takes to keep your Brothers alive, know their medical histories, know if you can share blood... "


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## Red Flag 1 (Jan 29, 2011)

surgicalcric said:


> I dont mind at all...
> 
> Okay folks...I would like to keep this thread alive.
> 
> ...



I agree, damn good thread! In the relatively "controlled" world of surgery I have the "luxury" of making a pretty acurate guess on estimated blood loss (EBL). To begin with, you have to first estimate the amount of blood you have to start with, or circulating blood volume. Then keep an eye on suction, laps, 4x4's, towels, and surgical field in general to determine blood loss. In some cases, peds in particular, I would often have the OR Nurses weigh all "sponges" to get as accurate a figure as I could. In general, I knew I could replace EBL with crystalloid (RL) at about a 3:1 rate ( crystalloid:blood), except in peds. In general, somewhere around 20% EBL thoughts would turn to replacing with Packed Red Blood Cells (PRBC's). Patients vital signs and continuing blood loss made the decision. Other things I could use would be Albumin ( increases onconic pull ), and Hetastarch. When things went bad in a hurry, vasopressers , along with crystalloids, could buy me time until I could get PRBC's in the room and into a pump and  warmer. Vasopressors included Ephedrine, Dopamine, Epi, Neo, and a few others. In surgery I have the ability to dramatically increase O2 dissolved in the plasma. This also buys me a lot of time. I can deliver 100% O2 at increased pressure to keep the tissues oxygenated with dissolved O2 vs combined in Hgb. So what of these things can be of value in the field?

EBL in the field could be estimated by looking at how much is being absorbed in clothing etc. That blood which is lost into surrounding soil/grass, and at night really makes it nearly impossible to determine EBL. If anyone has a handle on this, I would love to hear what it is! Patient vital signs, and uncontrolled bleeding are likely the best indicators for needing Red Blood Cells (RBC's). Crystalloids and non-RBC colloids are the next thing and 18D's know this already. Vasopressors are the next to reach for, along with the highest concentration of supplemental O2 that you can provide. Patient position is also a consideration. At any given moment, about 60% of circulating blood is in venous circulation. That having been said, simply elevating a lower extremity can add about  one unit of whole blood. Bottom line in the $.02 I have to offer, crystalloid, non-RBC colloid, vasopressors, position, and rapid evacuation are about it. The thought of direct transfusion seems cumbersome, and expensive in terms of combat team reduction. Would I consider it with the right donor-recipiant mix, and evac hours away, yes; he would be a team member after all.

So, criteria would include: ongoing poorly controlled blood loss, continued clinical picture of reversible shock, exhaustion of vasopressor supply, vasopressor tachyphylaxis, exhaustion of non-RBC colloid supply, near exhaustion of crystalloid supply, medical evacuation greater than 120 min. ETA, proper donor-recipiant match, needed equipment for direct transfusion, and a combat situation stable enough the loose another team member without endangering remaining team members.

Along with Crip, I'd like to hear more ideas on this issue.

RF 1


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## The91Bravo (Jan 29, 2011)

Thanks for the explanation, I appreciate it


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## pardus (Jan 30, 2011)

wow, thank you RF1!


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## Muppet (Jan 30, 2011)

surgicalcric said:


> I dont mind at all...
> 
> Okay folks...I would like to keep this thread alive.
> 
> ...




Crip: Are you talking about the indications for using Hextend or something else altogether?

F.M.


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## surgicalcric (Jan 30, 2011)

Firemedic said:


> Crip: Are you talking about the indications for using Hextend or something else altogether?
> 
> F.M.



I was talking about field blood transfusions FM.

Hextend has and is being given pretty widely in the field these days.

RF:

Great post; I will come back to some of that when I have a lil longer to type.

Keep it coming guys...


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## x SF med (Jan 30, 2011)

Estimation of blood loss in the field is half art, half science - extent of injury, vessel involvement, activity, and time are the major influencers... distractors are traumatic vasoconstriction, hydration levels, and time...  Yes, time is a player on both sides of the equation as it influences the volume available for loss.  At a loss rate of 100cc/ minute (~1 pint / minute) based on a normal 5000cc (5L)  volume in an avereage male with no reduction based on vlumetric slowing there is a 50 minute time period for total blood loss  at 3L loss the body cannot support blood flow - which is 30 minutes, in the field this is reduced to about a 15 minute window.  we now have a time frame.
Traumatic vasoconstriction buys up to 5 minutes, but cannot be counted on at all times.
So how do we figure the volumetric loss - we need to know involvement of the vessels and the out put ablity of those vessels - if the aorta is involved - in the field there is little hope of restoring circulation since you can lose 1L/minute and major organs will shut down quickly.  Femoral artery/vein - you can lose .5L/minute with full involvement - flow needs to stop ASAP...  Brachial artery/vein .25-.5L minute at full involvement.   this gives an idea of how much is going out....  use your time factors and you can estimate volumetric loss...
If times are unknown - the old school approaches are guides - cap refill at non involved extremities, cyanosis at thinly covered well supplied areas (lips, toenails, fingernails, ears....) to get an idea..., Pt LOC is another good indicator for blood loss...  taking all of these into account can get you pretty close to true blood loss in the field...  a fully involved femoral artery that has bled for 3 minutes with a 40 sec Traumatic vasoconstriction with minimal loss gives you a about a 1.5 l loss if the vessel is closed at that 3 minutes...

Is this a fair estimation? Does this make sense in light of RF1's question?


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## Chopstick (Jan 30, 2011)

I just want to interject from the sidelines.  This is getting my vote for thread of the year.  Very interesting and informative to the civi girl!


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## Red Flag 1 (Jan 30, 2011)

"Is this a fair estimation? Does this make sense in light of RF1's question?"

That works for me x SF med. Cap refill really does work. In the OR, the color of the conjunctive of a lower eyelid is a pretty good tip off as well. It should be a nice moist pink; pale and dry is hypovolemic and anemia. A criteria for direct transfusion should be that the wound is survivable; I felt that that was understood. Wounds to major vessels with little or no ability to directly or indirectly control hemorrhage can kill rapidly. The events that 18D's are dealing with are most challenging, even in the best of clinical settings. Complicate the job with poor lighting, minimal equipment, and hostiles all about trying to kill you is mind numbing. Just imagine dealing with a pelvic wound involving a femoral artery, and likely vein as well; not a lot of time to work with as x SF med outlined.


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## DoctorDoom (Feb 2, 2011)

surgicalcric said:


> It came to be after several guys died who could have possibly benefited from receiving whole blood in the field. I say possibly because the guys died before getting to a MTF of non-compressible hemorrhage and it isn't known whether they would have lived or not had they received the transfusion.



This is the part of field transfusion that bothers me... robbing Peter to pay Paul in a non-compressible hemorrhage situation, sure there is possible benefit, but ideally direct transfusion would be given before crystalloid dilution... it's a difficult decision to make.


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## surgicalcric (Feb 2, 2011)

DoctorDoom said:


> This is the part of field transfusion that bothers me... robbing Peter to pay Paul in a non-compressible hemorrhage situation, sure there is possible benefit, but ideally direct transfusion would be given before crystalloid dilution... it's a difficult decision to make.



Difficult decision indeed Sir, even more so when its a teammate.

P:

That was a very good description of EBL from our perspective.  Well done!

Crip


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## DoctorDoom (Feb 3, 2011)

Peripheral palpable pulse is also one estimate of BP and can help in evaluation of treatment without good EBL. In an unaffected extremity, radial pulse is approx 80mm Hg, femoral pulse approx 60mm Hg, people say carotid is 60 but it's probably closer to 40mm Hg. In young healthy adults hemorrhage class based on HR can be estimated and should give an idea of degree of blood loss. From there mode of rescus can be chosen.

Kentucky windage for sure, but in an austere environment or in a situation where BP cuffs aren't readily available, or you can't hear through the stethoscope, it's a way to clinically assess blood loss and begin treatment.


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## pardus (Feb 3, 2011)

In light of DD's post above, is there a chart or something that correlates BP to EBL?


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## DoctorDoom (Feb 3, 2011)

Not directly to BP but the following classification is the teaching:


Class I hemorrhage (loss of 0-15%)
In the absence of complications, only minimal tachycardia is seen.
Usually, no changes in BP, pulse pressure, or respiratory rate occur.
A delay in capillary refill of longer than 3 seconds corresponds to a volume loss of approximately 10%.


Class II hemorrhage (loss of 15-30%)
Clinical symptoms include tachycardia (rate >100 beats per minute), tachypnea, decrease in pulse pressure, cool clammy skin, delayed capillary refill, and slight anxiety.
The decrease in pulse pressure is a result of increased catecholamine levels, which causes an increase in peripheral vascular resistance and a subsequent increase in the diastolic BP.


Class III hemorrhage (loss of 30-40%)
By this point, patients usually have marked tachypnea and tachycardia, decreased systolic BP, oliguria, and significant changes in mental status, such as confusion or agitation.
In patients without other injuries or fluid losses, 30-40% is the smallest amount of blood loss that consistently causes a decrease in systolic BP.
Most of these patients require blood transfusions, but the decision to administer blood should be based on the initial response to fluids.


Class IV hemorrhage (loss of >40%)
Symptoms include the following: marked tachycardia, decreased systolic BP, narrowed pulse pressure (or immeasurable diastolic pressure), markedly decreased (or no) urinary output, depressed mental status (or loss of consciousness), and cold and pale skin.
This amount of hemorrhage is immediately life threatening.


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## Red Flag 1 (Feb 3, 2011)

DD,

Agree with 40 torr @ carotid.

RF 1


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## surgicalcric (Feb 3, 2011)

Some very good points are being introduced here.

RF1, DD:

You both bring up good points ranging from the difficulty of accurately estimating blood loss, which the Troll addressed as well as I have ever experienced - and will be plagiarizing in the near future, and the inherent troubles associated with transfusing whole blood vice packed RBCs, FFP, plasma, etc and all the while doing so in the field where combat effectiveness may be diminished.  This coupled with the ever looming possibility of taking more casualties makes for an even more difficult situation.  Then again, whoever said being an 18D (or other SOF medic forward mounted) was easy must have been a clinician...

On the note of decreased combat effectiveness of the guys who give up a unit of WB, the Swiss (I believe it was the Swiss) have been conducting studies measuring performance of soldiers pre/post transfusion.  They took a unit of WB from a group of guys then subjected them to a PT test and various combat related tasks to measure any decrease in performance.  They found that the decrease was negligible at best.  I will try to find the study in my notes; for those who attended SOMA in December it was discussed there.  Now, having said that everyone there and here is of the understanding that even though the test subjects performed well, the loss of blood to transfusion will result in a faster progression of shock if injured.  Just some food for thought on the topic...

 The use of vasopressors, while covered in training, isnt widely accepted in the field for a variety of reasons.  They require more equipment (60gtts/sets, 250 or 500ml bags of NS) and an even larger supply of meds (multidose 30ML vials of EPI 1:1000, Dopamine, etc..)  than we normally have on hand.  In addition, there is the chronotropic effects of both which will inherently increase O2 demand.  Everything I have read/been taught states that with either of the above vasopressors it is important to increase O2 available. Without the ability to increase O2 delivery to the patient I am again robbing Peter to pay Paul.

As for the crystalloid dilution which DD mentioned a couple posts back, it really isnt as much an issue; most of us (SOF/SF) carry more hextend than NS/LR.  I totally agree on the point made though.  The infusion needs to be addressed before the circulating volume is the consistency and color of pink lemonade.  lol.

Oh to be capable of addressing the issue of hemorrhage and its effects   in a controlled setting where the luxury of having "bright lights and   cold steel" isnt a luxury but the norm...  Then again, my ADHD ass would be bored...

--------

Keep it coming guys.


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## Muppet (Feb 3, 2011)

Damn I love this!

F.M.


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## policemedic (Feb 4, 2011)

surgicalcric said:


> On the note of decreased combat effectiveness of the guys who give up a unit of WB, the Swiss (I believe it was the Swiss) have been conducting studies measuring performance of soldiers pre/post transfusion. They took a unit of WB from a group of guys then subjected them to a PT test and various combat related tasks to measure any decrease in performance. They found that the decrease was negligible at best. I will try to find the study in my notes; for those who attended SOMA in December it was discussed there. Now, having said that everyone there and here is of the understanding that even though the test subjects performed well, the loss of blood to transfusion will result in a faster progression of shock if injured. Just some food for thought on the topic...



I want to say that was part of CPT Butler (US Navy SEAL, RET) and LTC Dhillon's (British Army) presentation, but I could be wrong.  I know they spoke about alternatives to hextend/whole blood.


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## x SF med (Feb 4, 2011)

> ...which the Troll addressed as well as I have ever experienced - and will be plagiarizing in the near future...



 It's not plagarism if I charge you royalties ....  one each fully stocked M-5 bag, and a case of *real-deal* John Wayne Bars  will get you lifetime unlimited use of a great number of Trollerific Trollisms and pearls of infinite wisdom ....  so many wonderful quotes for one low price.


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## Red Flag 1 (Feb 4, 2011)

In hospital settings, blood and blood products are carefully typed and cross matched (T&C), and double checked at every level prior to starting the administration. This is done to avoid the clinical disaster of a transfusion miss match/reaction; even with that, measures are in place to treat such an event. During my residency training, just after the Civil War (staying ahead of Crip, Purple, Troll, & JJ BPK,) some Clinical Prof's would use Phenergan and/or Benadryl to stay ahead of the curve should things not be just right. With direct blood transfusion, we are providing warm non-T&C whole blood. We are also delivering un-T&C products. IMHO, direct transfusion of blood should probably be proceeded with something to mitigate an immune response, I expect there may be some. Thoughts................

RF 1


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## kaja (Feb 4, 2011)

First, let me thank you guys. The amount of wisdom here is overwhelming.

I'd love to be able to contribute, but since I don't have as much experience under my belt as you guys, I'll try to stay in my lane.

Just few questions/ comments:

Taking BP by palpation- I came across this article ( http://www.bmj.com/content/321/7262/673.long ) and had discussion with one of our BATLS instructors about it. What we ended up with was that palpation doesn't give you accurate BP, but in addition to patient's LOC, EBL, injury nature and patient history (dehydration for example...) can give you pretty good idea what's happening. I was told again and again to look at patient from all possible angles and don't act only on one information (Like missing capillary refill... it's snowing outside 
	

	
	
		
		

		
			





). I know that you guys know that, but I just want to make sure I get it right, so in case i missed something let me know...

Effect of giving away one unit of blood- You guys don't donate blood, and go to PT directly after? Being 90kg guy, I never had any problem (Of course, the moment I'll get hit and start loosing blood I'll be in serious problem) and i assume that you won't be taking blood of your 50kg teammate or during firefight with risk of any injury to the donor.

Cross checking would be nice, and I assume that if you have you team members medical info, and can do cross-test prior to administration (just to be sure) you can get the risk to low level.

About the imunosupression- wouldn't that on the other side rise the risk of infection/ septic shock when we are talking about prolonged evacuation times? Of course post-transfusion reaction is much worse than possibility of infection...


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## Red Flag 1 (Feb 4, 2011)

"Cross checking would be nice, and I assume that if you have you team members medical info, and can do *a* cross-test prior to administration (just to be sure) you can get the risk to low level."

Great point kaja!! T&C'ing all team members would make direct blood transfusion in the field a bit more comfortable. I think that would be a great idea if DOD decides to use this option. Benadryl and Phenergan are antihistamines, both sedative. I would like steroids in my back pack to administer if needed, antibiotics in the hardened facility later, likely considered for many reasons.

RF 1


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## surgicalcric (Feb 5, 2011)

Red Flag 1 said:


> In hospital settings, blood and blood products are carefully typed and cross matched (T&C), and double checked at every level prior to starting the administration. This is done to avoid the clinical disaster of a transfusion miss match/reaction; even with that, measures are in place to treat such an event. During my residency training, just after the Civil War (staying ahead of Crip, Purple, Troll, & JJ BPK,) some Clinical Prof's would use Phenergan and/or Benadryl to stay ahead of the curve should things not be just right. With direct blood transfusion, we are providing warm non-T&C whole blood. We are also delivering un-T&C products. IMHO, direct transfusion of blood should probably be proceeded with something to mitigate an immune response, I expect there may be some. Thoughts................
> 
> RF 1



I believe I stated earlier that my guys have been T&C'd.  Every time we get a new guy T&C is part of med in-processing with me.  It is noted on his Cas Evac card, on both 18D's ODA casualty info card (name, last -4, allergies to meds, pertinent past med Hx, current meds and/or supplements, and T/C.  In the event we get an attachment down range, it was sudden -meaning I didnt have time to schedule a T&C before they got to me- and I dont have access to a FST/CSH I have Eldon cards on hand.  Are they idiot proof, no.  They are however better than going off someone's dogtags.

Pre-medication (Antihistamines and steroids) is taught as part of field transfusion for SF medics.    ;)

Keep it coming guys.


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## pardus (Feb 5, 2011)

surgicalcric said:


> Keep it coming guys.



Fuck yeah. This is opening my eyes wide.

The scary thing is that when I'm bringing this stuff to my med platoon, everyone including the PAs are saying "wow, this is interesting new stuff I didn't know."


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## TLDR20 (Feb 5, 2011)

kaja said:


> First, let me thank you guys. The amount of wisdom here is overwhelming.
> 
> I'd love to be able to contribute, but since I don't have as much experience under my belt as you guys, I'll try to stay in my lane.
> 
> ...



I honestly don't think there is a single 50KG SF guy on earth. Most guys are in the 80-100KG range at least. Alot of SF guys are corn fed barrel chested freedom fighters weighing in at around 85KG's, shit my ruck is normally heavier than 50KG's lol.


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## surgicalcric (Feb 6, 2011)

cback0220 said:


> ...Alot of SF guys are corn fed  barrel chested freedom fighters weighing in at around 85KG's, shit my  ruck is normally heavier than 50KG's lol.



Aint that the truth.  I dont remember when my ruck - operationally -  weighed less than 100 lbs.  And I dont think I have ever seen an SF guys  weighing less than 70KG...



			
				Sheep Shagger said:
			
		

> Fuck yeah. This is opening my eyes wide.
> 
> The scary thing is that when I'm bringing this stuff to my med platoon,  everyone including the PAs are saying "wow, this is interesting new  stuff I didn't know."



Pardus:

It  suprises me none in the least that your PA wasnt aware of its  existence.

 Keep reading and sharing...


Crip


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## Red Flag 1 (Feb 6, 2011)

_"I believe I stated earlier that my guys have been T&C'd."_

I believe you did mention that Crip; #70, and a huge advantage to have your "blood bank" walk to the field with you;). So you've got the whole blood to do a direct transfusion; how do you do that in the field? In the world of ER's, ICU's,andOR's, I've been able to transfuse a unit of cold, banked PRBC's into a patient in under five minutes of it getting in the room. Knowing that one size bigger IV line (18ga to 16ga) reduces resistance to flow to the fourth power,  I'll use the largest bore I can get into a usable vein. After cross checking of the unit to the patient, I dilute the PRBC's with NS to "thin the mix" some, plug in an inline blood filter, then into a blood pump with fluid warmer, hit the infuse button and the unit goes in........... right......... now. I'm curious to know what equipment would be used in the field for direct blood transfusions? The simplest, and least likely to fail, I can think of would be an inline three-way-stopcock, with a syringe attached to push the blood by direct manual injection. Would you consider using an in-line blood filter?

Thanks Crip!

RF 1


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## kaja (Feb 6, 2011)

BTW,  _Journal of Special Operations Medicine Volume 10, Edition 3 / Summer 10_ had article about whole blood transfusion.

http://www.socom.mil/jsom/documents/summer10vol10ed3.pdf

...I should found that one before asking here, but on the other hand it started quite informative topic. Sucking at Google-fu can be beneficial


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## Red Flag 1 (Feb 6, 2011)

kaja said:


> BTW,  _Journal of Special Operations Medicine Volume 10, Edition 3 / Summer 10_ had article about whole blood transfusion.
> 
> http://www.socom.mil/jsom/documents/summer10vol10ed3.pdf...I should found that one before asking here, but on the other hand it started quite informative topic. Sucking at Google-fu can be beneficial :cool:



Excellent post and reference, and I am glad that we have had the discussion we have been sharing here. I can't help but to agree with WFWB use vs banked and component products. Since the early '80's it became difficult to find whole blood to administer; the push for component therapy took over leaving PRBC's as the only choice for cell replacement. Banked blood does not deliver the viable red cells that WFWB can. I really like the thought of some Hextend for the donor for rehydration and promoting an onconic pull to the intravascular space. The question of other administered fluids, crystalloids in particular, I think suggests using them first to hydrate and replace volume as the WFWB is collected and prepared for use. The time required to type and cross match, collect the unit of blood and starting administration is said to be 30 min, I expect closer to an hour is more likely.

It's important to keep in mind that even the best possible conditions, hemolytic reactions to transfused blood and blood products can and do happen! I am very comfortable with the thought that 18D's are the ones to conduct direct blood transfusions. Their training and SA will make it as safe as possible.

Thanks again kaja for the reference and asking the question!

RF 1


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## pardus (Feb 6, 2011)

What steriods would be used for this?


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## surgicalcric (Feb 7, 2011)

Thanks for posting that link Kaja:  I had forgotten about the article.



Red Flag 1 said:


> ...The simplest, and least likely to fail, I can think of would be an inline three-way-stopcock, with a syringe attached to push the blood by direct manual injection. Would you consider using an in-line blood filter?
> 
> Thanks Crip!
> 
> RF 1



Did you get the equipment list from the article?  My list is pretty similar and it all rolls up into something akin to an airway/IV roll.  I utilize 180 micron filters in my sets BTW.

With the increased risk of lysing RBCs with manual injection I prefer to utilize gravity for the administration of FWB.  Just one more means of reducing the risk is how I see it.



			
				Pardus said:
			
		

> What steriods would be used for this?



Solu-Medrol is what I have on hand.

Crip


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## pardus (Feb 7, 2011)

What size needle/catheter are/would you be using with manual injection? We regularly use 25g needles with blood draws (cat/dog blood) with no lysing of RBCs providing you don't rush the draw/push.

I don't know Solu-Medrol, seems similar to Depo-Medrol from the quick search I did. My pharmacology is shite though...


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## surgicalcric (Feb 7, 2011)

pardus said:


> What size needle/catheter are/would you be using with manual injection? We regularly use 25g needles with blood draws (cat/dog blood) with no lysing of RBCs *providing you don't rush the draw/push*.
> 
> I don't know Solu-Medrol, seems similar to Depo-Medrol from the quick search I did. My pharmacology is shite though...



I use 16ga for both collection and administration.

As for the lysing, the key is in the emboldened text above; time.  There is a huge difference in 10cc draw and 450ml administration of FWB. With each minute that passes  the chances are something may happen which will cause the pressure to vary on the syringe and thus increasing the chance of the RBCs lysing.

Furthermore, this procedure isnt something which can be entrusted to another team guy; it MUST be done by the medic himself meaning he is tied to the syringe until the transfusion is complete.

Hope this better explains my position.

Crip


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## pardus (Feb 7, 2011)

Yes, Thank you.


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