Battlefield Blood

Transfusion

CPT James R. Rice, PA-C

Program Manager
Tactical Combat Medical Care
(TCMC)
 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 Albumin
Oxygen carrying Volume expander
capacity Whole Blood
No clotting factor
Provides oxygen
FFP carrying capacity
• No oxygen carrying Provides clotting
capacity factors
• Does have clotting Provides platelets
factor Provides volume
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 2-
11% 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 re-
charged!
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
Don’t put a lot of trust in “dog tags”
Keep a roster
Personnel that are co-located with you
• Cooks, mechanics, S-3/S-4 etc…
• Provide pre-coordination
Note that almost 50% of the population
is type “O”
 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 recipient’s blood
type if possible
Clean the donors arm for at least a
minute with povidone iodine
Using a blood collection system with
CPD, draw off approximately 450cc of
whole blood.
 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?