The concepts and suggested types of fluids for resuscitation are also discussed, including the use of blood and blood products.
Hemorrhagic Shock Fluid Resuscitation in Tactical Field Care (TFC)
During this third module addressing circulation assessment and management in the Tactical Field Care (TFC) setting, we will focus on fluid resuscitation for casualties experiencing hemorrhagic shock.
Although some shock assessment and recognition principles are taught in All Service Member or Combat Lifesaver training, this module discusses knowledge and procedures that fall under the purview of the Combat Medic.
There are 8 cognitive and 1 performance enabling learning objectives covered in this module.
After covering the progressive strategies for hemorrhagic shock fluid resuscitation, the techniques for prevention and treatment will be discussed. In addition to learning about the importance of early blood product administration, the indications and techniques for administering low-titer whole blood, fresh whole blood, plasma, and red blood cells will be reviewed. Additionally, identification and management of transfusion complications will be highlighted.
The performance objectives will be met through skills stations that involve learning how to type blood using an EldonCard®, how to collect blood, and how to transfuse blood products.
Circulation assessment and management is the “C” in the MARCH PAWS sequence.
Through the Joint Trauma System and the work of the Committee on Tactical Combat Casualty Care (CoTCCC), the ongoing process of evaluating casualty responses to fluid resuscitation has led to many modifications in the way we approach resuscitation. As recently as November of 2020, the guidelines on fluid resuscitation were updated to align with the most current evidence-based practices.
Initial TCCC recommendations, dating back to the late 1990s and early 2000s, were patterned largely after civilian trauma practices and “controlled hemorrhage” models, where the resuscitation was performed after further blood loss had been stopped (several of which were animal-based studies). Early studies were focused on maximizing the use of non-blood fluid products, as the logistics systems were not well-developed for pushing blood products forward in the battlefield space, and there were no FDA approvals or DoD policies to support battlefield blood product administration. In addition to standard crystalloid products, the use of Hextend®, and later PLASMA-LYTE A, were recommended as initial fluids of choice.
In 2003, the TCCC guidelines were updated to recommend blood products be carried on casualty evacuation platforms, when possible, and in 2006 that was expanded, and guidance on specific use of when to use Type O red blood cells was added. For the next several years, the focus on blood products was in Tactical Evacuation Care as the Services worked through the policy and logistics processes of being able to move blood product transfusions further forward.
Multiple studies looking at the results of fluid replacement in the absence of blood products were performed, and the resulting data demonstrated a lack of increased survival, or in many cases a decreased survival rate, and also demonstrated increased coagulopathy. As a result, the crystalloids, Hextend® and PLASMA-LYTE A were later de-prioritized to be used only if blood products were not available, and in 2014, the Tactical Field Care guideline revisions moved blood products to the forefront of care for those in hemorrhagic shock.
Through the hard work of many Combat Medics and with the evidence-based support of leadership, the policies on blood product administration were modified and the systems for getting blood to the battlefield have been improving ever since. Per the November 2020 TCCC guidelines, blood products are now the fluid of choice in hemorrhagic shock treatment; although there are still other clinical indications for crystalloid fluid replacement.
We’ll go over many of the details later in this module, but as a summary introduction, the current TCCC guidelines should serve as the basis for fluid resuscitation:
If a casualty does not have a weak or absent radial pulse, or altered mental status in the absence of traumatic brain injury (TBI), there is no need to fluid resuscitate them. Their trauma assessment and treatment can proceed, continuing with the MARCH-PAWS approach. Fluids by mouth are permissible if the casualty is conscious and can swallow, and they should be reassessed routinely. If they do develop signs of shock, appropriate treatments should be instituted.
Casualties who do show signs and symptoms of shock should have intravenous (IV) (or intraosseous (IO)) access established so that blood products can be administered.
The order of preference for blood products is:
Cold-stored low-titer O whole blood
Pre-screened low-titer O fresh whole blood
Plasma, red blood cells (RBCs) and platelets in a 1:1:1 ratio
Plasma and RBCs in a 1:1 ratio
Plasma or RBCs alone
Hypothermia prevention measures need to be established, and after the first unit of blood products is transfused, one gram of calcium should be administered.
The patient should be reassessed after each unit, and resuscitation should be continued until mental status improves, a radial pulse is palpable, or a systolic BP of 100 mm Hg is achieved. Once achieved, the IV or IO should be secured and the rest of the MARCH-PAWS assessment and treatment can resume, if it hasn’t already been accomplished.
Reassess the casualty frequently to check for recurrence of shock. If shock recurs, recheck all external hemorrhage control measures to ensure that they are still effective and repeat fluid resuscitation, as necessary.
The best prevention for hemorrhagic shock is, by far, controlling all sources of bleeding. Ongoing blood loss will impede the ability to successfully treat shock. A casualty with known blood loss, even if controlled and not currently in shock, is at higher risk of developing shock during the treatment and evacuation phases and should be monitored very closely.
Dehydration from potential delays in evacuation and the environment is likely and can lead someone who has very little reserve into a state of shock. Oral rehydration, if the casualty can swallow, is appropriate and recommended, and the risk of emesis and aspiration is judged to be very low in casualties given only oral fluids for rehydration if they need to undergo surgery. Additionally, consider the need for placing a saline lock in casualties with significant injuries. Having a saline lock in place may increase the odds of a favorable outcome for someone at significant risk of shock by saving time between when they show signs of shock and when they are treated.
As just mentioned, there is ever-increasing evidence that fluid resuscitation for casualties in hemorrhagic shock is best accomplished with fluid that is identical to that lost by the casualty — whole blood. Large volumes of crystalloids and/or colloids may worsen coagulopathy and increase bleeding; whereas blood products not only replace the lost volume but often replace components that promote clot maintenance and remain within the vascular system instead of seeping into soft tissues because of osmotic pressure differences.
As a reminder, for treatment of hemorrhagic shock the fluid selection priorities are:
Cold-stored low-titer O whole blood
Pre-screened low-titer O fresh whole blood
Plasma, red blood cells (RBCs) and platelets in a 1:1:1 ratio
Plasma and RBCs in a 1:1 ratio
Plasma or RBCs alone
IV or IO access is necessary for fluid resuscitation and was discussed in detail in a prior module. Blood products can safely be administered through an 18-gauge catheter, and larger bore catheters are often more difficult to establish in a tactical environment so should be avoided for the most part.
Hypothermia is a significant consideration in all trauma, but even more so if transfusing blood products, particularly cold-stored blood. Battery-powered fluid warming devices can raise the temperature of fluids as they are infused. Although there is not a specific device recommendation, you should use one that is able to achieve a 38°C output temperature at a flow rate up to 150 ml/min. And other hypothermia prevention and treatment measures should be instituted as soon as possible, as well.
Ideally, you will have access to pre-screened blood products, and the risk of a transfusion reaction will be minimal. However, in some cases, transfusion of unscreened group O fresh whole blood or type-specific fresh whole blood may be necessary. This results in an increased risk for a potentially lethal hemolytic reaction and should only be performed by appropriately trained medical personnel. Keep in mind that if Rh-negative blood products are not immediately available, Rh-positive blood products should be used in hemorrhagic shock. The risk of an adverse outcome from hemorrhage is often greater than the risk of a reaction in those cases.
Hypocalcemia is a significant risk with rapidly transfused blood products, as the citrate preservative binds to the patient's endogenous calcium, rendering calcium inactive. One gram of calcium should be given after transfusing the first unit of blood products. That can be done using 30 ml of 10% calcium gluconate or using 10 ml of 10% calcium chloride. Of note, necrosis and skin sloughing are known to occur when calcium chloride extravasates during a peripheral IV administration, and careful monitoring should be emphasized to avoid this complication.
It is also important to note that more is not always better. End-points for fluid replacement have been established for several reasons. One is that blood products on the battlefield are an extremely limited resource and should be managed with care. The other is that higher than necessary blood pressures and intravascular volumes can disrupt clot formation and contribute to rebleeding in some cases. Although particularly true in studies using crystalloids and colloids, this is still a consideration with blood products, as well.
The end points for blood transfusion are defined in the TCCC guidelines as:
A palpable radial pulse
Improved mental status
Systolic BP of 100 mm Hg (of note, the target SBP for a casualty with TBI is 100-110 mm Hg)
The casualty should be reassessed after every transfusion of a unit of blood products, and when one of these end points is met, the resuscitation should be stopped. However, the risk for recurrent shock is always present, and frequent reassessment, with early return to fluid resuscitation, should be a priority.
Calcium Administration
DOSAGE(S)
Calcium 1 gm IV daily
ROUTE(S)
Calcium is available in IV or IO form
INDICATIONS
For use after blood product transfusions
CONTRAINDICATIONS
Contraindicated in patients with ventricular fibrillation, hypercalcemia, hypophosphatemia, or renal calculi; use cautiously in digitalized patients and patients with sarcoidosis, renal or cardiac disease, respiratory acidosis, or respiratory failure; potential benefits may warrant use in pregnant women despite potential risks if the alternative is worse.
POTENTIAL SIDE EFFECTS
Tingling sensations, headache, irritability, weakness, syncope with rapid IV injection, mild decrease in blood pressure, vasodilation, bradycardia, arrhythmias, rebound hyperacidity, nausea polyuria, renal calculi, hypercalcemia, and local reactions
DRUG INTERACTIONS
Decreased bioavailability with atenolol, fluoroquinolones and tetracyclines, calcium channel blockers decrease calcium effectiveness, cardiac glycosides increase digitalis toxicity, thiazide diuretics cause a risk of hypercalcemia
ONSET/PEAK/DURATION
Immediate/immediate/1-2 hr
TACTICAL CONSIDERATIONS
Administer one gram of calcium as either 30 ml of 10% calcium gluconate or 10 ml of 10% calcium chloride; immediately after the first transfused blood product. Monitor calcium chloride infusion closely as severe necrosis and skin sloughing can occur if peripheral IV extravasates.
Current guidelines emphasize that transfusion should occur as soon as possible after life-threatening hemorrhage in order to keep the patient alive.
A retrospective cohort study of 502 U.S. military combat casualties in Afghanistan between 2012 and 2015 showed that time to initial blood product transfusion was associated with reduced 24-hour and 30-day mortality. And in a civilian study, the multicenter Prehospital Air Medical Plasma trial, civilian trauma patients also showed a similar reduction in mortality.
One of the keys to early blood product administration is ensuring that the processes to move blood from collections sites to forward locations are in place. For cold-stored low-titer O whole blood, the collection and processing are done at designated donor centers in the US, through the Armed Services Blood Program, and blood is shipped to combat operational theater storage areas where they remain in electric-powered monitored refrigerators as far forward as tactically feasible. The blood is then transferred to a single unit, commercially available, battery-operated 50-hour containers that can hold 1-2 units of whole blood. Those smaller, battery-operated containers can be brought to far forward positions, allowing for the early use of blood products.
Prescreened donors (or unscreened donors) can also be used to provide blood early on at forward locations. However, the time that is required is often longer than cold stored blood because of the need to collect the blood prior to donation, and possibly the need to blood type donors and casualties prior to the collection or transfusion of blood products.
Although using blood products later in the course of a casualty’s treatment is definitely better than not using them, the earlier the casualty’s blood losses are replaced, the better the potential outcome. Prioritize blood product resuscitation efforts both in mission planning and during casualty assessment and treatment.
The preferred fluid for hemorrhagic shock resuscitation is cold-stored low-titer O whole blood (LTOWB).
Low-titer refers to the anti-A and anti-B antibodies present in the plasma component of Type O whole blood. Titer levels vary and require a lab test that is not field expedient, so must be determined prior to the Tactical Field (or Evacuation) Care phase.
Thresholds for what constitutes low-titer differ. In World War II, the Army Blood Program noted mild transfusion reactions in whole blood with titers >512, and one severe transfusion reaction of a titer of 8000. In response, the Army Blood Program defined low-titer group O whole blood as being < 250.4, and this program carried over to the Korean and Vietnam conflicts (although the logistics system was not able to move blood to the battlefield on a routine basis, and the majority of the transfusions occurred in medical treatment facilities, not forward locations).
When the standards committee of the American Association of Blood Banks recently updated the standard of care to endorse the use of group O low-titer whole blood for recipients of known or unknown ABO group in hemorrhagic shock, the door was opened for FDA approval and for the DOD to develop processes to use blood in forward settings. Taking historical and current studies into consideration, the blood program has established new guidelines – and currently, low-titer is defined as <256.
There are several advantages to using cold-stored LTOWB. Cold-stored LTOWB has already undergone transmissible disease testing (for FDA compliance), titer testing, and leukocyte reduction before being stored. Additionally, if it is present at the forward location it can be administered as soon as IV or IO access has been established in the casualty. And, in common with fresh whole blood from pre-screened donors, at least one study has demonstrated improved outcomes when compared to component therapy with whole blood components. Lastly, there is only one product to store and transport.
One disadvantage is the shelf-life which, at 21 or 35 days (depending on the preservative) is less than packed RBCs and fresh-frozen plasma (42 days and one year, respectively). Another is the need to maintain a cold chain to the point of transfusion, which requires significant logistical support.
The methods of transfusing blood products are essentially the same for whole blood, packed RBCs, thawed plasma, and platelets.
Prior to initiating a transfusion, casualties should have already had all external hemorrhage controlled, IV or IO access established, and tranexamic acid should have been administered.
Before beginning a cold-stored low-titer Type O whole blood transfusion, ensure that a filter is in place in the blood tubing. Filters remove clots and small clumps of platelets and white blood cells that form during collection and storage.
Additionally, the tubing should be routed through an IV fluid warmer, set to warm the blood to 38°C (100.4°F). And when feasible, other hypothermia prevention measures should be instituted as quickly as possible.
As with any infusion, the tubing should all be primed before beginning flow to the casualty and sterile procedures used unless the tactical situation prevents that from happening. The recommended standard for transfusion is to have the blood products infusing within 5 minutes of the time you begin the process.
After the initial unit of blood, 1 gm of calcium should be administered IV or IO.
Assess for and treat blood transfusion reactions:
Anaphylactic reaction (hives, itching, stridor/shortness of breath, and/or hypotension
Then the casualty should be reassessed to see if they meet the criteria for discontinuation of resuscitation – the return of radial pulses or a systolic BP >100 or improved mental status. If these parameters aren’t met, then continue resuscitation attempts, reassessing after every unit.
Despite increased access to FDA-approved, screened, and banked LTOWB in combat theaters, the demand for whole blood may exceed the supply. Another way to access whole blood in the TCCC setting if cold-stored LTOWB is not available is to utilize fresh whole blood, collected at or near the point of transfusion.
Ideally, fresh whole blood donors have been pre-screened and selected based on having low-titer type O blood and passed appropriate infectious disease testing. Group-specific donors may be appropriate for group-specific transfusion (e.g., A to A), but keep in mind that estimates indicate blood type on identification tags is about 4% inaccurate. However, sometimes prescreening hasn’t been accomplished and untitered type O blood is still appropriate. This approach has been used successfully by the 75th Ranger Regiment, resulting in evidence-based protocols and procedures that may be adopted by other units.
Several of the advantages of cold-stored whole blood apply to fresh whole blood, but there are a couple of disadvantages. One is that additional time is needed to collect the blood, which may delay its administration, and possibly reduce its efficacy. Another is that during the collection process, one or more of the combatants involved in the operation will be indisposed as they donate (or help with the collection of the donation); using support and non-mission essential personnel will reduce the negative impact on operations during collection.
One potential advantage, if an IV fluid warmer is not available, is that a fresh transfusion may not add to hypothermia issues as much as a cold-stored transfusion. Also, if a cold chain is not available for logistics reasons, this process is still viable.
The actual administration of fresh whole blood doesn’t differ from cold-stored whole blood, including the use of IV fluid warmers, if available.
In the absence of whole blood, either cold-stored or fresh, packed red blood cells (RBCs), platelets, and plasma in a 1:1:1 ratio should be used. If three-component therapy isn't available, then use Plasma and RBCs in a 1:1 ratio. When whole blood is separated, platelets have a short shelf-life of 5 days at room temperature and 15 days refrigerated and preserved, while plasma has a shelf-life of 5 days once thawed and 40 days when frozen. Plasma or RBCs alone are indicated when a casualty is in hemorrhagic shock and whole blood is not available.
RBC units may be stored for up 35-42 days under refrigeration depending on the preservative used, which may be slightly longer than some whole blood. And the removal of the plasma during the separation process means that there is minimal concern about the donor’s titer status.
Red blood cells and plasma are transfused in the same way, with the same considerations, as whole blood.
After initiating any blood product transfusion, the casualty should be monitored closely for complications. Simple issues like dislodged infusion tubing or infiltrated infusion sites occur intermittently and are managed by establishing alternate access sites or changing supplies. But the main concern is the potential for an adverse reaction to the blood products.
The two main categories of severe reactions are anaphylaxis and acute hemolysis. Anaphylaxis is a severe, potentially life-threatening allergic reaction. Signs of anaphylaxis include stridor from edema of the airways and/or pharynx, shortness of breath and/or hypotension. This may be preceded by hives or itching. However, these may be difficult to assess in the tactical environment. Likewise, tachycardia is not particularly helpful as your casualty is inevitably tachycardic from the hemorrhagic shock you are addressing.
Hemolysis is the rupture of red blood cells and leakage of their contents, usually due to mismatch or incompatibility between the casualty and the donor blood products. The classic acute hemolytic transfusion reaction is described as a fever, flank pain, and red or brown urine; but in the field all three findings rarely occur. The pain may be in an arm, the chest or the back or disseminated intravascular coagulation may be present. And these signs may be preceded by nausea.
If these reactions occur, the transfusion should be stopped immediately and appropriate treatment for the reaction initiated. For both reaction types, the blood product transfusion should be replaced by a lactated Ringer’s or normal saline infusion.
If the patient is in anaphylaxis, the treatment of choice is 0.3ml of 1:1000 epinephrine intramuscularly (IM). This is the 0.3 mg dose found in a standard EpiPen®. Additionally, administer 25 mg of diphenhydramine, either IM or by slow IV push. It is also very important to monitor the airway, as obstructions due to soft tissue swelling can compromise the ability to move air freely. If available, you could also consider administering 10-40 mg of methylprednisolone by slow IV push.
If the patient is having an acute hemolytic reaction, the treatment of choice is 25 mg of diphenhydramine, either IM or by slow IV push.
Once any reaction is stabilized, the next step is to find another compatible blood product and resume resuscitation, if possible.
Epinephrine Administration
DOSAGE(S)
0.3 mg (3 ml of 1:1000 solution), repeated every 5 to 10 minutes as necessary
ROUTE(S)
IM or subcutaneous
INDICATIONS
Emergency treatment of anaphylaxis or allergic reactions.
CONTRAINDICATIONS
None
POTENTIAL SIDE EFFECTS
Anxiety, restlessness, tremor, weakness, dizziness, sweating, palpitations, pallor, nausea and vomiting, headache, disorientation, and tachycardia
DRUG INTERACTIONS
Antihypertensives reduce the pressor effects of epinephrine, thyroid hormones, antihistamines, and some anti-arrhythmic medications increase its arrhythmogenic effects.
ONSET/PEAK/DURATION
15-30 sec (IM
TACTICAL CONSIDERATIONS
Standard EpiPens® deliver the recommended 0.3 mg IM dose. Casualties in hemorrhagic shock have poor tissue perfusion to their extremities reducing the delivery of epinephrine; use large muscle groups closest to the torso (in order of preference: thigh > deltoid > gluteal).
Diphenhydramine Administration
DOSAGE(S)
25 mg initial dose, may consider 50 mg based on clinical situation; repeat q 4-6 hr prn; max daily dose 300 mg
ROUTE(S)
IM, IO & IV
INDICATIONS
Emergency treatment of anaphylaxis or allergic reactions
CONTRAINDICATIONS
Documented hypersensitivity to diphenhydramine, breastfeeding mothers, use in pregnancy if clearly needed.
Accentuates effects of other medications that cause drowsiness or decreased level of consciousness (sedatives, hypnotics)
ONSET/PEAK/DURATION
10 sec-20 min (IV
TACTICAL CONSIDERATIONS
There is no evidence to support H1‐antihistamines alone in emergency management of anaphylaxis – diphenhydramine should only be used as an adjunct to epinephrine during anaphylaxis management; the slower onset and longer duration may help sustain effects of successful treatment. Useful for minor reactions that are not life-threatening. Casualty weapons, communications, and sensitive equipment should be secured.
Methylprednisolone Administration
DOSAGE(S)
10-40 mg
ROUTE(S)
Slow IV or IO push (over one minute)
INDICATIONS
Blood product transfusion anaphylactic reaction
CONTRAINDICATIONS
Systemic fungal infections and known hypersensitivity (prior allergic reaction); potential benefits may warrant use in pregnant women despite potential risks if the alternative is worse.
Accentuates effects of other medications that cause drowsiness or decreased level of consciousness (sedatives, hypnotics)
ONSET/PEAK/DURATION
Immediate/1-2 min/1 hr
TACTICAL CONSIDERATIONS
Administer 10-40 mg IV or IO, after first administering epinephrine and diphenhydramine, when treating an anaphylactic reaction from a blood product transfusion.
This video will go over the proper techniques for administering blood products in a Tactical Field Care setting.
ADMINISTRATION OF BLOOD PRODUCTS IN TACTICAL FIELD CARE
This video will go over the proper techniques for administering cold stored blood products in a Tactical Field Care setting.
ADMINISTRATION OF COLD STORED BLOOD PRODUCTS IN TACTICAL FIELD CARE
Although the fact that whole blood provides the best physiologic response to fluid resuscitation has been evident for quite a while, logistical challenges in getting whole blood far forward led to the need to consider alternative strategies. Lyophilized plasma was developed in the 1930s and used during WWII and Korea but discontinued afterward due to disease transmission. Several countries including France, Germany, and South Africa continued to develop and improve the process and have been actively using freeze-dried plasma in forward, austere locations for many years.
CoTCCC and the Defense Health Board began looking at potential options for using plasma, and in 2011 recommended expediting access to dried plasma for Combat Medics. Additional efforts led to the Food & Drug Administration approval of French freeze-dried plasma (FDP) for U.S. military forces for the treatment of hemorrhagic shock. And several US-based companies are developing FDP products for FDA consideration.
Plasma provides fibrinogen as well as other hemostatic factors. It also restores lost intravascular volume. Although best combined with other blood components (red blood cells and platelets), there is added value in using FDP as a stand-alone component, if other blood products are not available.
Dried plasma can be stored without refrigeration and may be carried and used by combat medical personnel when transfusion of other blood components is not logistically feasible.
Administration of plasma involves a reconstitution step not needed with other blood products. FDP may come with both components (the lyophilized plasma and the diluent to reconstitute it) or as the FDP alone, requiring the unit/medic to have the appropriate diluent available in their supplies. For example, the French FDP that has been used by the US military in recent years comes in a 2-vial kit.
Once reconstituted, the plasma can then be administered like other blood products. In those cases when vials are being used, administration requires vented tubing; but when reconstituted in a collapsible bag, vented tubing is not required and standard blood tubing can be used. Thawed fresh-frozen plasma is administered this way.
As with any blood product, be sure to watch for adverse reactions, as previously discussed.
There are several markers on red blood cells that determine a donor or casualty’s blood type. The main ones are the ABO surface markers (antigens) and the Rh antigen. In transfusing for hemorrhagic shock, these are the markers that are most important and also the markers that can be determined outside of a laboratory. Other minor markers are often assessed when finding the most compatible donor for an elective transfusion when full lab capabilities are present.
ABO blood typing can be done using an EldonCard. This card has antigens impregnated on its surface, and when a donor’s or casualty’s blood is placed on the card and reacts with those antigens, the reaction (or lack of reaction) can be used to determine a person’s ABO and Rh status. Oftentimes, the EldonCard is part of a blood-typing kit that includes lancets, blood collecting sticks, and a water dropper – but the cards may come alone, as well.
Blood typing of a casualty in hemorrhagic shock may not be appropriate if low-titer type O blood is available, as it would delay the resuscitation efforts needlessly. For group-specific transfusions (e.g., B to B) in donors and casualties who have not had their blood typed recently (or the validity of prior typing is in question), blood typing using EldonCards is appropriate.
This video will go over the proper techniques for typing donor or casualty blood in a Tactical Field Care setting using the EldonCard.
ELDON CARD TECHNIQUES IN TACTICAL FIELD CARE
Collecting blood in a field setting involves several considerations that are not necessarily issues when collecting in a medical facility. The collection process involves establishing IV access, collecting the blood, and then preparing the collected blood for transfusion. Blood typing should be done prior to collection, if it has not already been done.
Although we previously mentioned that blood products can be administered through an 18-gauge needle, the collection should be done using the 16-gauge needle that accompanies the collection bag. Your donor will not be dehydrated or have been losing blood so should have adequate veins to establish access with the 16-gauge needle. If a saline lock has already been established, it is acceptable to insert the 16-gauge needle into the saline lock port to tap that vein and see if blood can easily be donated through that access point.
The next step is to collect the blood. In general, the lower the bag below the donor’s heart the faster it will fill. There are citrate-based anticoagulants in the bag and gently agitating the bag from side to side can help distribute the citrate evenly. Overfilling the bag can exhaust the anticoagulants and lead to clotting, so there are a few methods to prevent that from happening. The collection bag can have a 6.5-inch zip tie or beaded cable tie placed around its middle, or the bottom 1-1½ inches can be folded and clamped, and when the flow is stopped due to the resistance it will be full. Alternatively, a piece of parachute cord measuring 10 inches can be placed around the center and the flow can be stopped when the ends pull apart. If a scale were available, the bag and blood should weigh 585 gm, but it is unlikely that option will be available in the tactical environment.
Although infrequent, observe for lightheadedness or vasovagal reactions with nausea and vomiting, the most common adverse events in donors.
The third step is to prepare for transfusion. The donation should be stopped by clamping the tubing and discontinuing the IV access while applying a little pressure to the venipuncture site with a bandage. The donation lines attached to the bag should be knotted in two locations with overhand knots. Then, the blood should be moved to the recipient and the transfusion initiated as soon as possible.
It should be noted that studies have demonstrated that although donors do experience some decline in oxygen-carrying capacity, highly trained military personnel continued to perform well both at submaximal and maximal effort levels and there was no decline in cognitive function.
This video will go over the proper techniques for collecting blood in a Tactical Field Care setting.
The third part of circulation management in TFC focuses on fluid resuscitation for casualties in hemorrhagic shock. Early resuscitation with whole blood, cold-stored if available or fresh if not available, is the priority in treating hemorrhagic shock.
We talked about the progressive strategies for hemorrhagic shock fluid resuscitation, including the importance of early blood product administration and the indications and techniques for administering whole blood, plasma, and red blood cells. Additionally, we highlight the identification and management of transfusion complications.
We also discussed how to type blood using the EldonCard and the proper techniques for collecting blood in the field environment
During the skills stations reviewing the use of an EldonCard, the process for collecting blood, and learning how to transfuse blood products. You should have developed or improved your skills for performing these procedures in a battlefield.
This information and even more so these skills are definitely perishable. It is extremely important that you take every opportunity to repeat formal and informal training and maintain your proficiency in these skills that are not used frequently but are critical to achieving the best outcome for your casualty.
To close out this module, check your learning with the questions below (answers under the image).
Check on learning
Answers
What signs of hemorrhagic shock are indications that fluid resuscitation is needed?
A casualty with a weak or absent radial pulse, or altered mental status in the absence of traumatic brain injury (TBI), needs fluid resuscitation.
What is the preferred product for hemorrhagic fluid resuscitation?
The order of preference for blood products is cold-stored low-titer O whole blood; pre-screened low-titer O fresh whole blood; plasma, red blood cells (RBCs) and platelets in a 1:1:1 ratio; plasma and RBCs in a 1:1 ratio; and plasma or RBCs alone.
When should calcium be administered during fluid resuscitation?
After the initial unit of blood products, 1 gm of calcium should be administered IV or IO.
When should fluid resuscitation be discontinued?
The casualty should be reassessed to see if they meet the criteria for discontinuation of resuscitation – the return of radial pulses or a systolic BP >100 or improved mental status.
What is an advantage of freeze-dried plasma?
Dried plasma can be stored without refrigeration and may be carried and used by combat medical personnel when transfusion of other blood components is not logistically feasible.
