Dr. Meaghan Keville, MD, is an emergency physician with Air Force Special Operations and currently a staff member at CSTARs Baltimore. She shares her experience with blood resuscitation in the deployed environment and lessons that will be filtering to the civilian world in the future.
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Meaghan Keville (00:01):
Good morning everyone. My name is Megan cavil
I'm an active duty, US Air Forceem physician at the Center for
sustainment of trauma andreadiness skills at the our
Adams Callie Shock Trauma Centerin Baltimore, Maryland.
Today, I'd like to take sometime to talk about blood product
usage and the operationalenvironment, a fresh look at a
(00:23):
topic that's been part ofOperational Medicine for many
years, what we use, why we useit, and a bit about the nuts and
bolts of how to manage bloodproducts outside of the
hospital. I'd like to start bysharing a case with you from a
recent deployment to get youthinking. I was part of a pair
of two small surgical teamsforward staged at a role to for
(00:48):
a known high risk operation. Wereceived the following
information via radio call.
There was an American soldierwho had been shot multiple
gunshot wounds with obvious paidpenetrating injuries as you see
listed for report. He'dinitially lost consciousness but
was now awake and talking. Atourniquet had been placed to
(01:08):
the right arm. A sternal IO wasplaced and the above medications
had been administered. Thepatient arrived to a role to
approximately 17 minutes afterinjury via helicopter with two
medics are somewhat impromptuteam included a vascular
surgeon, a transplant surgeon,an orthopedic surgeon, to CRNAs
(01:30):
to emergency physicians, a nursepractitioner and an ICU nurse
and addition the role to head toorganic 18 Deltas. As we began
her primary assessment, we foundthe following the tourniquet to
the right arm and left leg withbilateral groins packed there
(01:51):
were no current active bleeding.
His airway was intact and he hada palpable pulse in the groin
that was able to be assessed.
There was no visible headinjury. However, he was notably
confused. He was brought inwrapped in a warming blanket. Or
a secondary assessment was nomore reassuring. Initial vital
(02:14):
signs demonstrated a heart rateof 94 respirations of 24, an
initial blood pressure of 73over 23 and an O two set of 79%
on room air. He was assessed tohave approximately 11 gunshot
wounds to the right chest,flank, lower abdomen, bilateral
groins and left leg. As theresuscitation began, he was
(02:37):
intubated receive bilateralchest tubes and a seven French
sheath was placed in the rightcommon femoral artery, he was
prepared for damage controlsurgery. During this time, the
walking blood bank was activatedby the organic 18 Delta's seen
here is their prep station.
(02:58):
Thankfully, a thing of absoluteperfection. From clean supplies
ready at hand to the step bystep reminders artistically
created on some leftover packingStyrofoam. Our patient underwent
exploratory laparotomy was zoneone reboa placed times two for a
total of 26 minutes of combinedocclusion and partial occlusion
(03:19):
time. The abdomen was packed toportions of small bowel or
resected and a pelvicretroperitoneal hematoma was
noted but not unroofed. At therole to I start results during
his stay at the role two areshown here. Arrival ph 7.1 With
lactate of 9.32 final rule toICESat ph 7.2. Lactate 7.5.
(03:45):
During his day there he received37 units of whole blood between
point of injury and arrival atrule 317 of which being warm,
fresh whole blood from thewalking blood bank. He was
transported via fixed wingaircraft to a role three where
he underwent initial evaluationand resuscitation. Here is his
(04:06):
chest X ray on arrival. Here'shis X ray of the abdomen with
multiple fragments still presentin the right upper quadrant and
pelvis. Additionally, althoughdifficult to see on this image,
three Ebola which was left inplace with balloon deflated can
be appreciated traversing uptowards the diaphragm. And
(04:28):
lastly, here's his pelvis X ray.
Again, with visible fragmentsand bilateral groins as well as
deep in the pelvis. The reboacatheter can again be
appreciated here.
It was quickly identified thatthis patient would likely
require more resuscitation thaneven the role three had the
(04:49):
capability for the patient wastaken back to the operating room
and the walking blood bank wasactivated. Base wide via big
voice announcement. Donors lineup out the door and around the
block to contribute over 150units were drawn in less than a
few hours. A second emergentexploratory laparotomy and wound
(05:13):
wash out was performed. Thepelvic hematoma was at this
point unroofed and he was foundto have bilateral iliac vein
injuries. Ultimately, one commoniliac ended up being ligated and
the opposite external iliac wasligated as well. He remained
intubated but stable in the ICUfor the next two days. In the
(05:36):
first 12 hours of hisresuscitation, this patient
received a total of 132 units ofproduct combined 73 of these
units were whole blood, multipleof them, oh positive, but
untitled due to the shortage.
Thankfully, he suffered none ofthe well known complications of
(05:56):
severe multi trauma with massivetransfusion, such as trolly arts
or renal failure. He wastransported back to the United
States via Seacat. And shortlyafter excavated, I'm pleased to
report that he has successfullycompleted rehab and return to
his family and to active duty.
(06:20):
This case is one example of howimportant a working knowledge of
blood product utilization andlogistics is in the operational
environment to all providers.
During the conflicts in Iraq andAfghanistan between 2003 and
2012 14%, of patients admittedto a rural three military
(06:40):
treatment facility received atransfusion of at least one
blood product. Of these 35%received massive transfusion,
defined as greater than 10 unitsof red blood cells or whole
blood in 24 hours. Theproportion of transfused
patients receiving massivetransfusion reached
approximately 50% by 2011. Inparallel with increasing injury
(07:02):
severity scores, use of bloodproduct resuscitation, and
decreased use of crystalloid andcolloid use. Multiple studies
have demonstrated that earlyblood product resuscitation
provides the lowest mortalityrates both early and late. The
ABC or assessment of bloodconsumption score was developed
(07:22):
out of Vanderbilt University asa simple way of predicting
massive transfusion. Any two ofthe four components listed here
is 75%, sensitive and 86% perspecific for determining a
massive transfusion event. A fewother scores can also be
helpful, but are slightly morecomplicated that TASH or trauma
(07:44):
associated severe hemorrhage andMcLaughlin scores can also be
utilized but are slightly morecomplex and utilize laboratory
values. Multiple studies incivilian literature suggest a
shock index of greater than oneto be indicative of a trauma
patient that will likely requiremassive transfusion. A recent
study by marinko at Al out ofMadigan Army Medical Center and
(08:06):
Scripps Mercy Hospitalretrospectively reviewed the DoD
trauma registry to demonstrateto them that a shock index of
0.8 is a significant predictorof the need for massive
transfusion and emergencysurgical procedures in the
combat environment. As we moveon to discuss the resuscitation
of those sick trauma patients,I'll take a moment to step onto
(08:29):
my favorite soapbox. The use ofIV fluids for resuscitation can
be traced back to 1831 during aparticularly deadly cholera
outbreak in London, althoughmaybe a good thing for cholera
patients, we've learned that fortrauma patients sailing is not
beneficial. I'm sure many of uscan remember a time where a TLS
(08:52):
recommended the administrationof two liters of crystalloid
prior to the administration ofany blood product. How times
have changed. The a TLS 10thedition now identifies that
resuscitation with greater than1.5 liters of crystalloid is
associated with increasedmortality dilutional
coagulopathy, abdominalcompartment syndrome, multiple
(09:14):
organ failure and death andsuggest limiting crystalloid use
to no more than one leaderduring the initial
resuscitation. My argument isthat if blood is what's on the
floor, it is what your patientneeds. The Committee
on tactical combat casualty caretends to agree. And their
(09:37):
recommendations for choice ofresuscitation fluid and the
shock trauma patient are here.
If you'll note options 1234 Andfive all involve some form of
blood product. whole blood as aresuscitation fluid is not a new
concept. Documented us datingback as early post World War Two
(09:59):
and the Korean War as seen inthis set of photos here.
However, whole blood fell out offavor in the 1960s and 1970s,
when separation of blood intoits components became common
practice in order to conserveblood as a resource and utilize
only the components necessary.
(10:19):
Although this was an effectivemethod of improving storage
times and decreasing waste, thechange was not data driven. And
there was little to no evidenceto support therapeutic
equivalence or superiority overher whole blood, particularly
and the trauma patientpopulation. However, there are
(10:39):
many reasons as to why wholeblood is an ideal choice for the
resuscitation of the acutely illtrauma patient. For those math
majors out there, here's a sideby side comparison of whole
blood versus component therapycomposition. whole blood notably
has higher MI, hemoglobin andhematocrit, higher platelet
count and improve clotting incomparison to component therapy.
(11:02):
Additionally, component therapyrequires multiple different
storage modes, and ultimately,patients receive various
products for multiple differentdonors. Increasing overall
inflammation and antibodypresents an important
consideration for futuretransfusion needs. To put it
simply, for those of us thataren't as fond of public math,
(11:24):
one can compare a single unit ofwhole blood to the combined
component therapy volume,depending on your blood bank,
roughly 300 ml per unit ofextraneous crystalloid, or
anticoagulant. Hopefully at thispoint, you might agree with me
that blood products are theideal choice of resuscitation
(11:46):
and trauma patient, and thatwhole blood is the icing on that
cake. But this may leave youwith the question, how does
blood get from the donor to mypatient downrange? In short,
it's a bit complicated. However,the armed services blood
distribution system is aworldwide system for bringing
(12:09):
blood products to those who needit. The logistics of this
machine are beyond the scope ofthis discussion. However, let's
take a closer look at thefactors you should know as an
end user. Wherever you findyourself if there is not a blood
bank on site, blood will mostlikely arrive to you in a
(12:29):
Columns box like seeing here, itcan hold up to 30 units of blood
with the appropriate 14 poundsor more of what ice or 15 units
of fresh frozen plasma with its20 to 30 pounds of pelleted dry
ice. Both products can be keptat temperature for roughly 48
hours in this fashion. Althoughsomewhat dependent on the
(12:49):
outside temperature. The GoldenHour box is a means for
transporting smaller amounts ofproduct for shorter periods of
time away from refrigeration. Afew important points about the
golden hour and minute boxes arethat they must be frozen prior
to use and require typically 24hours of freeze time. They must
(13:10):
be removed from the freezer andallowed to sit for 30 minutes
before inserting any product.
Once appropriately packed thebox will maintain a temperature
of one to six degrees for up to72 hours. Golden Hour boxes can
carry up to four units of PRBCor three units of FFP golden
minute typically two units ofproduct. important notes are
(13:32):
that these containers do expire.
You can check the expirationdates online using serial
numbers and it is important notto use these containers without
all insert components, they willbe unlikely to maintain their
temperature if they do not haveall of the pieces. Blood
(13:56):
Products storage should becarefully monitored downrange
and without a blood bank. Keepin mind you may find yourself
managing this daily temperaturecheck should be monitored as
well as stock expiration dates.
Seen here is an example of thefridge freeze most commonly
utilized. I've included the AirForce regulation for reference,
but would presume each servicelikely has a similar similar
(14:16):
one. Let's take a minute to deepdive on each of the products you
might utilize and how you'llneed to manage them in an
operational environment.
Codes stored whole blood isbecoming the most frequently
seen blood product downrange. Itcan be stored from one to six
(14:40):
degrees Celsius and maintainsits robust platelet function for
up to 14 days. It can beutilized for up to 35 days
depending on which preservativeit has been drawn with. Some
blood banks in the United Stateswill cycle these units back to
split into component therapy ifnot utilized within the first
four 10 days to decrease wastagegiven packed red cells can be
(15:03):
stored longer. We'll catch up onthat in a minute. Fresh whole
blood can either be stored atroom temperature and used within
24 hours of collection and thendestroyed if not used, or it can
be refrigerated within eighthours of collection. After which
point it is referred to aswalking blood bank stored whole
(15:26):
blood. A few words regarding theuse of fresh whole blood at the
time of the development of thislecture. Not all deploying
personnel are currently requiredto be tighter to go downrange.
Fresh whole blood low titer Ohwhole blood is considered to
have best when having a titer ofless than one to 256 Anti A and
(15:48):
anti B. This is something that JTTS is continuing to work on.
However, it is important forthose in leadership to consider
those deploying to areas wherethis may be utilized must
recognize that maintaining abattle roster with all deployed
personnel as blood type can belife saving. Lastly, this
process takes time eveninexperienced hands and takes
(16:11):
experienced hands to execute.
Having supplies readilyavailable for use and multiple
trained personnel to manage thewalking blood bank may also be
life saving. packed red bloodcells are still a mainstay of
therapy and then trauma patientboth in the United States and
deployed. Depending on thepreservative they can be stored
(16:31):
for up to 35 days or 42 days andRefrigeration at one to six
degrees Celsius. Typically seeonly a navy environment is also
frozen red blood cells. Redblood cells that have been
specifically treated and frozenwith glycerol cryo precipitant
that can be stored for up to 10years at negative 65 degrees
(16:53):
Celsius. Of note. When these redblood cells are ready for
utilization, they must be thawedand rinsed in an automated
process prior to transfusionthat takes a few hours and some
special equipment. AB plasma isclassically considered the
(17:13):
universal donor. However, it isnow widely recognized that a
plasma can in fact be considereduniversal. Since Group A
individuals do not generallymake high titer anti B
antibodies and B red cellsexpress the B antigen at such
low depths density that they aremuch less susceptible to
hemolysis than a red cells.
(17:37):
fresh frozen plasma should bestored at minus 18 degrees
Celsius or colder and whenstored this way, can have a
frozen shelf life ofapproximately a year. thawed
plasma after being thought and a37 degree water bath for
approximately 30 minutes priorto transfusion has a shelf life
of approximately five days.
Liquid or never frozen plasmacan be stored for up to 26 days
(18:01):
or 40 days depending on itspreservative. Freeze Dried
plasma or French military freezedried plasma is available to us
special operations forces underan emergency use authorization
from the FDA. You can see a vialin the bottom right corner of
(18:24):
this slide. Pre reconstitutionit has a two year shelf life.
After reconstitution the shelflife is approximately four
hours. currently in developmentis what you see in the top right
corner freeze dried plasma madein the US that will not come in
a glass bottle. You may findyourself wondering, how does a
(18:48):
person create a 37 degree waterbath for thawing frozen plasma
in an operational environment.
Thawing frozen plasma it takestime and it's somewhat
unpredictable given one quarterof FFP units will be unusable
when thawed due to brokenpackaging as a result of the
freezing thawing process. Fordeployed teams have used many
(19:10):
different methods, includingeverything from Emory heating
elements, electric kettles andcrackpots to accomplish this
task, the favored device by fardue to its ability to provide
specific temperature control aswell as its many different
alternate uses is this cvwdThere are two recent studies
that looked at this problem indifferent ways. Mala do at Al's
(19:33):
paper, feel the experienceexpedient thawing of fresh
frozen plasma from transfusionin the year 2020 utilized only
FFP and multiple differentwarmers to attempt to determine
the most efficient one that doesnot affect the function of the
plasma. Their resultsdemonstrated that the superior
solution with respect to timingwas the Soviet immersion
(19:55):
circulator requiring theshortest amount of time to
repair the water and the Namount of time to thoughts
similar to the clinical thar.
This device maintained bathtemperature accuracy as the
clinical thar as well, evenafter adding in the two units of
FFP. Additionally shown here aresome selected images from the
November 2020 military medicinearticle expeditionary immersion
(20:19):
circulating heating device apromising technique for treating
frostbite injuries and warmingIV fluids in a forward deployed
cold weather environment,demonstrating that the Soviet is
not only helpful for the thawingof FFP, but also for warming
blood and frostbittenextremities. In contrast to red
cells and plasma plateletscollected in theater by
(20:42):
apheresis traditionally had beenstored at room temperature under
constant agitation for a maximumof five days. Refrigerated
storage has been shown to betterpreserve platelet hemostatic
function and clearly reduce therisk of bacterial growth. The
major hazard of trans using roomtemperature stored platelets.
Cold stored platelets have beenproven effective in clinical
(21:06):
trials and recently usedsuccessfully in combat trauma
patients in the US that comearea of operations, called soar,
platelets and platelet additivesolution or plasma retain
function for at least 15 daysand are compatible with blood
warmers and a rapid infuser. Forthose of us, like myself, who
(21:26):
have trouble keeping straight,all of the who gets what, when
it comes to blood products. Hereis a simple chart that keeps
things straight as a reminderbrought to you from the joint
United Kingdom blood transfusionand tissue transplantation
service. Here are a couple offinal reminders for those of us
(21:50):
that aren't typically the onesactually hanging the blood. Or
if massive transfusion isn't apart of your daily practice.
Early administration of calciumis recommended. One gram of
calcium either 30 ml of 10%Calcium glucan eight or 10 mils
of 10% Calcium Chloride IV or IOshould be given to patients in
(22:11):
hemorrhagic shock during orimmediately after the
transfusion of the first unit ofblood product and with ongoing
resuscitation after every fourunits of product. Ideally,
ionized calcium should bemonitored and serum and calcium
should be given for an ionizedcalcium less than 1.2. Although
it may not always be commonpractice in the United States,
(22:33):
this is a reminder that it isacceptable and encouraged to
spike blood tubing with bloodproducts. Blood Products can
also be administered with PlasmaLight and normal saline.
However, it is not recommendedto accompany blood products with
calcium containing fluids orhypotonic fluids. The importance
of preventing hypothermia cannotbe overemphasized. transfusing a
(22:57):
trauma, patients with roomtemperature or cold fluids will
only worsen the effects oftrauma induced coagulopathy poor
enzymatic function and DIC,expediting the arrival of your
triage of death. However,finding fluid warmers with
strong battery life, appropriatewarming capabilities and flow
rates that do not take upsignificant amounts of weight
(23:21):
and cue at a reasonable costcontinues to be a problem under
investigation for the DOD. Shownhere are a few examples of
current available equipment. Istrongly suggest becoming
familiar with the equipment youwill utilize when preparing for
any downrange mission. Each ofthese has their own nuances and
fail points that requiremitigation.
(23:46):
I leave you with a few partingwords written by Captain J. S
Mahone US Navy and his 1970military medicine paper and in
Korean into the nature of woundsresulting in killed in action in
Vietnam, that I still believering true that American and
Allied servicemen and womencontinue to receive the best
(24:06):
hospital medical care possible,even in the worst of places. And
that things like rapid use ofwhole blood rapid treatment
either via transport of patientto hospital or hospital to
patient. And the hard work ofthe people listening to this
talk to continue to improveoperational care every day
brings service members willingto risk their lives home to
(24:28):
their loved ones when they'reinjured. Thank you for your time
and attention today. And withthat open the floor to any
questions
Good morning everyone. My name is Megan cavil
I'm an active duty, US Air Forceem physician at the Center for
sustainment of trauma andreadiness skills at the our
Adams Callie Shock Trauma Centerin Baltimore, Maryland.
Today, I'd like to take sometime to talk about blood product
usage and the operationalenvironment, a fresh look at a
(00:23):
topic that's been part ofOperational Medicine for many
years, what we use, why we useit, and a bit about the nuts and
bolts of how to manage bloodproducts outside of the
hospital. I'd like to start bysharing a case with you from a
recent deployment to get youthinking. I was part of a pair
of two small surgical teamsforward staged at a role to for
(00:48):
a known high risk operation. Wereceived the following
information via radio call.
There was an American soldierwho had been shot multiple
gunshot wounds with obvious paidpenetrating injuries as you see
listed for report. He'dinitially lost consciousness but
was now awake and talking. Atourniquet had been placed to
(01:08):
the right arm. A sternal IO wasplaced and the above medications
had been administered. Thepatient arrived to a role to
approximately 17 minutes afterinjury via helicopter with two
medics are somewhat impromptuteam included a vascular
surgeon, a transplant surgeon,an orthopedic surgeon, to CRNAs
(01:30):
to emergency physicians, a nursepractitioner and an ICU nurse
and addition the role to head toorganic 18 Deltas. As we began
her primary assessment, we foundthe following the tourniquet to
the right arm and left leg withbilateral groins packed there
(01:51):
were no current active bleeding.
His airway was intact and he hada palpable pulse in the groin
that was able to be assessed.
There was no visible headinjury. However, he was notably
confused. He was brought inwrapped in a warming blanket. Or
a secondary assessment was nomore reassuring. Initial vital
(02:14):
signs demonstrated a heart rateof 94 respirations of 24, an
initial blood pressure of 73over 23 and an O two set of 79%
on room air. He was assessed tohave approximately 11 gunshot
wounds to the right chest,flank, lower abdomen, bilateral
groins and left leg. As theresuscitation began, he was
(02:37):
intubated receive bilateralchest tubes and a seven French
sheath was placed in the rightcommon femoral artery, he was
prepared for damage controlsurgery. During this time, the
walking blood bank was activatedby the organic 18 Delta's seen
here is their prep station.
(02:58):
Thankfully, a thing of absoluteperfection. From clean supplies
ready at hand to the step bystep reminders artistically
created on some leftover packingStyrofoam. Our patient underwent
exploratory laparotomy was zoneone reboa placed times two for a
total of 26 minutes of combinedocclusion and partial occlusion
(03:19):
time. The abdomen was packed toportions of small bowel or
resected and a pelvicretroperitoneal hematoma was
noted but not unroofed. At therole to I start results during
his stay at the role two areshown here. Arrival ph 7.1 With
lactate of 9.32 final rule toICESat ph 7.2. Lactate 7.5.
(03:45):
During his day there he received37 units of whole blood between
point of injury and arrival atrule 317 of which being warm,
fresh whole blood from thewalking blood bank. He was
transported via fixed wingaircraft to a role three where
he underwent initial evaluationand resuscitation. Here is his
(04:06):
chest X ray on arrival. Here'shis X ray of the abdomen with
multiple fragments still presentin the right upper quadrant and
pelvis. Additionally, althoughdifficult to see on this image,
three Ebola which was left inplace with balloon deflated can
be appreciated traversing uptowards the diaphragm. And
(04:28):
lastly, here's his pelvis X ray.
Again, with visible fragmentsand bilateral groins as well as
deep in the pelvis. The reboacatheter can again be
appreciated here.
It was quickly identified thatthis patient would likely
require more resuscitation thaneven the role three had the
(04:49):
capability for the patient wastaken back to the operating room
and the walking blood bank wasactivated. Base wide via big
voice announcement. Donors lineup out the door and around the
block to contribute over 150units were drawn in less than a
few hours. A second emergentexploratory laparotomy and wound
(05:13):
wash out was performed. Thepelvic hematoma was at this
point unroofed and he was foundto have bilateral iliac vein
injuries. Ultimately, one commoniliac ended up being ligated and
the opposite external iliac wasligated as well. He remained
intubated but stable in the ICUfor the next two days. In the
(05:36):
first 12 hours of hisresuscitation, this patient
received a total of 132 units ofproduct combined 73 of these
units were whole blood, multipleof them, oh positive, but
untitled due to the shortage.
Thankfully, he suffered none ofthe well known complications of
(05:56):
severe multi trauma with massivetransfusion, such as trolly arts
or renal failure. He wastransported back to the United
States via Seacat. And shortlyafter excavated, I'm pleased to
report that he has successfullycompleted rehab and return to
his family and to active duty.
(06:20):
This case is one example of howimportant a working knowledge of
blood product utilization andlogistics is in the operational
environment to all providers.
During the conflicts in Iraq andAfghanistan between 2003 and
2012 14%, of patients admittedto a rural three military
(06:40):
treatment facility received atransfusion of at least one
blood product. Of these 35%received massive transfusion,
defined as greater than 10 unitsof red blood cells or whole
blood in 24 hours. Theproportion of transfused
patients receiving massivetransfusion reached
approximately 50% by 2011. Inparallel with increasing injury
(07:02):
severity scores, use of bloodproduct resuscitation, and
decreased use of crystalloid andcolloid use. Multiple studies
have demonstrated that earlyblood product resuscitation
provides the lowest mortalityrates both early and late. The
ABC or assessment of bloodconsumption score was developed
(07:22):
out of Vanderbilt University asa simple way of predicting
massive transfusion. Any two ofthe four components listed here
is 75%, sensitive and 86% perspecific for determining a
massive transfusion event. A fewother scores can also be
helpful, but are slightly morecomplicated that TASH or trauma
(07:44):
associated severe hemorrhage andMcLaughlin scores can also be
utilized but are slightly morecomplex and utilize laboratory
values. Multiple studies incivilian literature suggest a
shock index of greater than oneto be indicative of a trauma
patient that will likely requiremassive transfusion. A recent
study by marinko at Al out ofMadigan Army Medical Center and
(08:06):
Scripps Mercy Hospitalretrospectively reviewed the DoD
trauma registry to demonstrateto them that a shock index of
0.8 is a significant predictorof the need for massive
transfusion and emergencysurgical procedures in the
combat environment. As we moveon to discuss the resuscitation
of those sick trauma patients,I'll take a moment to step onto
(08:29):
my favorite soapbox. The use ofIV fluids for resuscitation can
be traced back to 1831 during aparticularly deadly cholera
outbreak in London, althoughmaybe a good thing for cholera
patients, we've learned that fortrauma patients sailing is not
beneficial. I'm sure many of uscan remember a time where a TLS
(08:52):
recommended the administrationof two liters of crystalloid
prior to the administration ofany blood product. How times
have changed. The a TLS 10thedition now identifies that
resuscitation with greater than1.5 liters of crystalloid is
associated with increasedmortality dilutional
coagulopathy, abdominalcompartment syndrome, multiple
(09:14):
organ failure and death andsuggest limiting crystalloid use
to no more than one leaderduring the initial
resuscitation. My argument isthat if blood is what's on the
floor, it is what your patientneeds. The Committee
on tactical combat casualty caretends to agree. And their
(09:37):
recommendations for choice ofresuscitation fluid and the
shock trauma patient are here.
If you'll note options 1234 Andfive all involve some form of
blood product. whole blood as aresuscitation fluid is not a new
concept. Documented us datingback as early post World War Two
(09:59):
and the Korean War as seen inthis set of photos here.
However, whole blood fell out offavor in the 1960s and 1970s,
when separation of blood intoits components became common
practice in order to conserveblood as a resource and utilize
only the components necessary.
(10:19):
Although this was an effectivemethod of improving storage
times and decreasing waste, thechange was not data driven. And
there was little to no evidenceto support therapeutic
equivalence or superiority overher whole blood, particularly
and the trauma patientpopulation. However, there are
(10:39):
many reasons as to why wholeblood is an ideal choice for the
resuscitation of the acutely illtrauma patient. For those math
majors out there, here's a sideby side comparison of whole
blood versus component therapycomposition. whole blood notably
has higher MI, hemoglobin andhematocrit, higher platelet
count and improve clotting incomparison to component therapy.
(11:02):
Additionally, component therapyrequires multiple different
storage modes, and ultimately,patients receive various
products for multiple differentdonors. Increasing overall
inflammation and antibodypresents an important
consideration for futuretransfusion needs. To put it
simply, for those of us thataren't as fond of public math,
(11:24):
one can compare a single unit ofwhole blood to the combined
component therapy volume,depending on your blood bank,
roughly 300 ml per unit ofextraneous crystalloid, or
anticoagulant. Hopefully at thispoint, you might agree with me
that blood products are theideal choice of resuscitation
(11:46):
and trauma patient, and thatwhole blood is the icing on that
cake. But this may leave youwith the question, how does
blood get from the donor to mypatient downrange? In short,
it's a bit complicated. However,the armed services blood
distribution system is aworldwide system for bringing
(12:09):
blood products to those who needit. The logistics of this
machine are beyond the scope ofthis discussion. However, let's
take a closer look at thefactors you should know as an
end user. Wherever you findyourself if there is not a blood
bank on site, blood will mostlikely arrive to you in a
(12:29):
Columns box like seeing here, itcan hold up to 30 units of blood
with the appropriate 14 poundsor more of what ice or 15 units
of fresh frozen plasma with its20 to 30 pounds of pelleted dry
ice. Both products can be keptat temperature for roughly 48
hours in this fashion. Althoughsomewhat dependent on the
(12:49):
outside temperature. The GoldenHour box is a means for
transporting smaller amounts ofproduct for shorter periods of
time away from refrigeration. Afew important points about the
golden hour and minute boxes arethat they must be frozen prior
to use and require typically 24hours of freeze time. They must
(13:10):
be removed from the freezer andallowed to sit for 30 minutes
before inserting any product.
Once appropriately packed thebox will maintain a temperature
of one to six degrees for up to72 hours. Golden Hour boxes can
carry up to four units of PRBCor three units of FFP golden
minute typically two units ofproduct. important notes are
(13:32):
that these containers do expire.
You can check the expirationdates online using serial
numbers and it is important notto use these containers without
all insert components, they willbe unlikely to maintain their
temperature if they do not haveall of the pieces. Blood
(13:56):
Products storage should becarefully monitored downrange
and without a blood bank. Keepin mind you may find yourself
managing this daily temperaturecheck should be monitored as
well as stock expiration dates.
Seen here is an example of thefridge freeze most commonly
utilized. I've included the AirForce regulation for reference,
but would presume each servicelikely has a similar similar
(14:16):
one. Let's take a minute to deepdive on each of the products you
might utilize and how you'llneed to manage them in an
operational environment.
Codes stored whole blood isbecoming the most frequently
seen blood product downrange. Itcan be stored from one to six
(14:40):
degrees Celsius and maintainsits robust platelet function for
up to 14 days. It can beutilized for up to 35 days
depending on which preservativeit has been drawn with. Some
blood banks in the United Stateswill cycle these units back to
split into component therapy ifnot utilized within the first
four 10 days to decrease wastagegiven packed red cells can be
(15:03):
stored longer. We'll catch up onthat in a minute. Fresh whole
blood can either be stored atroom temperature and used within
24 hours of collection and thendestroyed if not used, or it can
be refrigerated within eighthours of collection. After which
point it is referred to aswalking blood bank stored whole
(15:26):
blood. A few words regarding theuse of fresh whole blood at the
time of the development of thislecture. Not all deploying
personnel are currently requiredto be tighter to go downrange.
Fresh whole blood low titer Ohwhole blood is considered to
have best when having a titer ofless than one to 256 Anti A and
(15:48):
anti B. This is something that JTTS is continuing to work on.
However, it is important forthose in leadership to consider
those deploying to areas wherethis may be utilized must
recognize that maintaining abattle roster with all deployed
personnel as blood type can belife saving. Lastly, this
process takes time eveninexperienced hands and takes
(16:11):
experienced hands to execute.
Having supplies readilyavailable for use and multiple
trained personnel to manage thewalking blood bank may also be
life saving. packed red bloodcells are still a mainstay of
therapy and then trauma patientboth in the United States and
deployed. Depending on thepreservative they can be stored
(16:31):
for up to 35 days or 42 days andRefrigeration at one to six
degrees Celsius. Typically seeonly a navy environment is also
frozen red blood cells. Redblood cells that have been
specifically treated and frozenwith glycerol cryo precipitant
that can be stored for up to 10years at negative 65 degrees
(16:53):
Celsius. Of note. When these redblood cells are ready for
utilization, they must be thawedand rinsed in an automated
process prior to transfusionthat takes a few hours and some
special equipment. AB plasma isclassically considered the
(17:13):
universal donor. However, it isnow widely recognized that a
plasma can in fact be considereduniversal. Since Group A
individuals do not generallymake high titer anti B
antibodies and B red cellsexpress the B antigen at such
low depths density that they aremuch less susceptible to
hemolysis than a red cells.
(17:37):
fresh frozen plasma should bestored at minus 18 degrees
Celsius or colder and whenstored this way, can have a
frozen shelf life ofapproximately a year. thawed
plasma after being thought and a37 degree water bath for
approximately 30 minutes priorto transfusion has a shelf life
of approximately five days.
Liquid or never frozen plasmacan be stored for up to 26 days
(18:01):
or 40 days depending on itspreservative. Freeze Dried
plasma or French military freezedried plasma is available to us
special operations forces underan emergency use authorization
from the FDA. You can see a vialin the bottom right corner of
(18:24):
this slide. Pre reconstitutionit has a two year shelf life.
After reconstitution the shelflife is approximately four
hours. currently in developmentis what you see in the top right
corner freeze dried plasma madein the US that will not come in
a glass bottle. You may findyourself wondering, how does a
(18:48):
person create a 37 degree waterbath for thawing frozen plasma
in an operational environment.
Thawing frozen plasma it takestime and it's somewhat
unpredictable given one quarterof FFP units will be unusable
when thawed due to brokenpackaging as a result of the
freezing thawing process. Fordeployed teams have used many
(19:10):
different methods, includingeverything from Emory heating
elements, electric kettles andcrackpots to accomplish this
task, the favored device by fardue to its ability to provide
specific temperature control aswell as its many different
alternate uses is this cvwdThere are two recent studies
that looked at this problem indifferent ways. Mala do at Al's
(19:33):
paper, feel the experienceexpedient thawing of fresh
frozen plasma from transfusionin the year 2020 utilized only
FFP and multiple differentwarmers to attempt to determine
the most efficient one that doesnot affect the function of the
plasma. Their resultsdemonstrated that the superior
solution with respect to timingwas the Soviet immersion
(19:55):
circulator requiring theshortest amount of time to
repair the water and the Namount of time to thoughts
similar to the clinical thar.
This device maintained bathtemperature accuracy as the
clinical thar as well, evenafter adding in the two units of
FFP. Additionally shown here aresome selected images from the
November 2020 military medicinearticle expeditionary immersion
(20:19):
circulating heating device apromising technique for treating
frostbite injuries and warmingIV fluids in a forward deployed
cold weather environment,demonstrating that the Soviet is
not only helpful for the thawingof FFP, but also for warming
blood and frostbittenextremities. In contrast to red
cells and plasma plateletscollected in theater by
(20:42):
apheresis traditionally had beenstored at room temperature under
constant agitation for a maximumof five days. Refrigerated
storage has been shown to betterpreserve platelet hemostatic
function and clearly reduce therisk of bacterial growth. The
major hazard of trans using roomtemperature stored platelets.
Cold stored platelets have beenproven effective in clinical
(21:06):
trials and recently usedsuccessfully in combat trauma
patients in the US that comearea of operations, called soar,
platelets and platelet additivesolution or plasma retain
function for at least 15 daysand are compatible with blood
warmers and a rapid infuser. Forthose of us, like myself, who
(21:26):
have trouble keeping straight,all of the who gets what, when
it comes to blood products. Hereis a simple chart that keeps
things straight as a reminderbrought to you from the joint
United Kingdom blood transfusionand tissue transplantation
service. Here are a couple offinal reminders for those of us
(21:50):
that aren't typically the onesactually hanging the blood. Or
if massive transfusion isn't apart of your daily practice.
Early administration of calciumis recommended. One gram of
calcium either 30 ml of 10%Calcium glucan eight or 10 mils
of 10% Calcium Chloride IV or IOshould be given to patients in
(22:11):
hemorrhagic shock during orimmediately after the
transfusion of the first unit ofblood product and with ongoing
resuscitation after every fourunits of product. Ideally,
ionized calcium should bemonitored and serum and calcium
should be given for an ionizedcalcium less than 1.2. Although
it may not always be commonpractice in the United States,
(22:33):
this is a reminder that it isacceptable and encouraged to
spike blood tubing with bloodproducts. Blood Products can
also be administered with PlasmaLight and normal saline.
However, it is not recommendedto accompany blood products with
calcium containing fluids orhypotonic fluids. The importance
of preventing hypothermia cannotbe overemphasized. transfusing a
(22:57):
trauma, patients with roomtemperature or cold fluids will
only worsen the effects oftrauma induced coagulopathy poor
enzymatic function and DIC,expediting the arrival of your
triage of death. However,finding fluid warmers with
strong battery life, appropriatewarming capabilities and flow
rates that do not take upsignificant amounts of weight
(23:21):
and cue at a reasonable costcontinues to be a problem under
investigation for the DOD. Shownhere are a few examples of
current available equipment. Istrongly suggest becoming
familiar with the equipment youwill utilize when preparing for
any downrange mission. Each ofthese has their own nuances and
fail points that requiremitigation.
(23:46):
I leave you with a few partingwords written by Captain J. S
Mahone US Navy and his 1970military medicine paper and in
Korean into the nature of woundsresulting in killed in action in
Vietnam, that I still believering true that American and
Allied servicemen and womencontinue to receive the best
(24:06):
hospital medical care possible,even in the worst of places. And
that things like rapid use ofwhole blood rapid treatment
either via transport of patientto hospital or hospital to
patient. And the hard work ofthe people listening to this
talk to continue to improveoperational care every day
brings service members willingto risk their lives home to
(24:28):
their loved ones when they'reinjured. Thank you for your time
and attention today. And withthat open the floor to any
questions
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