Direct blood transfusion

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.
 
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.
 
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...
Click to expand...

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

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.
 
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
 
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
eek.png
). 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...
 
"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
 
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
Click to expand...

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.
 
surgicalcric said:
Keep it coming guys.
Click to expand...

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."
 
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.

Just few questions/ comments:

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.
Click to expand...

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.
 
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.
Click to expand...

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."
Click to expand...

Pardus:

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

Keep reading and sharing...


Crip
 
"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
 
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:
Click to expand...

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
 
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
Click to expand...

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?
Click to expand...

Solu-Medrol is what I have on hand.

Crip
 
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...
 
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...
Click to expand...

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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