Finger wave day was fun too... NOT.
Direct blood transfusion
- Thread starter kaja
- Start date
Finger wave day was fun too... NOT.
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
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.
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
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.
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"
It was a good feeling.
policemedic
Verified SWAT
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.
That must have put a smile on your face!
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
Purple
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... "
Red Flag 1
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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
Thanks for the explanation, I appreciate it
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...
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?
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?
Red Flag 1
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"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.
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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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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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.
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.
