Blood Transfusions, Reactions, and More

From a reader.

Thoughts from the medical types?

8 responses to “Blood Transfusions, Reactions, and More

  1. I am a surgeon, and have performed a few hundred laparotomies and thoractomies for penetrating trauma over the course of 31 years of training and practice, 6 of them as an attending trauma surgeon at two level 1 centers, one in a MSMA of several million people and quite busy. Concordantly, I have ordered the transfusion of a lot of blood products. The information in this article is factual and practical for a combat medic with logistical support. I do not believe it is applicable in a practical sense for most anticipated grid-down scenarios.
    Care of the modern penetrating trauma patient with life-threatening injuries to the torso, head and neck or proximal extremity, from pre-hospital stabilization to discharge home is labor-intensive, costly and resource-based. Dozens of doctors, nurses, therapists and technicians are involved. Equipment is often technologically advanced, but most importantly available for use and re-use in unlimited fashion. Inventory of both routine and critical items, such as blood products, is maintained. Area blood banks support the effort, with occasional, often seasonal, shortages. A gunshot wound to the abdomen or chest in a single patient, to somewhere like the iliac or subclavian vessels, pulmonary hilum, liver or retrohepatic vena cava can consume and cutely deplete a hospital’s and even regional blood bank’s supplies.
    And still people die.
    I am not denigrating the author or the information, but grid-down means just that. Those level 1 centers will be on generator until the diesel or natural gas run out. There will be no resupply of the just-in-time inventory on their shelves. What is a layperson and even a completely prepared surgeon, stocked with basic inventory and equipment, capable of addressing those problems, going to do? And, for that matter, sustain?
    I am not trying to be cynical, pessimistic or defeatist. Just realistic, and pragmatic. Triage will take on new meaning and importance. Major penetrating trauma in the grid-down world, especially high-velocity rifle injuries, will generally mean death. The bright spot is that the opioids you will need to provide comfort to the dying, sad as it may be, seem readily available. I’ll take the heroin, if it’s me.

  2. Correction: MMSA (My phone spit out the acronym for the stare medical association)
    “acutely” rather than cutely depleted

    Hey, it’s early

  3. There are, AFAIK, dozens of antibodies that can make it extremely hard to match blood donors to donated blood, and the actual blood type (A/B/O) and Rh factor (+ or -) are only the primary two. In a SHTF life-and-death scenario, you can expect far more frequent reactions to the multitude of things you aren’t and cannot test for, without a functioning first-world blood bank.

    So yes, you can play the game without all the parts, just be aware that the chips are the lives of your patients, and you’re going to lose some.
    When your donor and recipient pool are no longer healthy, fit, 18-25 y.o. males (which the military not only has, but relies on having in most cases), the number of adverse reactions will increase even more.

    A hemolytic transfusion reaction is a serious complication that can occur after a blood transfusion. The reaction occurs when the red blood cells that were given during the transfusion are destroyed by the person’s immune system.

    There are other types of allergic transfusion reactions that do not cause hemolysis.

    But the hemolytic type can kill you. All those non-compatible blood cells blown apart by your immune response literally clot your circulation (DIC), particularly in in the kidneys (your blood system’s filter), followed by kidney failure and death. Mis-typing mistakes currently whack about 40-50 people/yr in the US from exactly that cause, out of several million transfusions/yr. Being that rare is fine, as long as it’s not you, nor your patient on the hit list. Oh, and severe trauma – the exact situation envisaged for needing to do field transfusion – notably increases the risk of DIC.

    The article is good overall, if a bit sloppy. (e.g., the advice to have “9% saline” is idiotically wrong; you want 0.9% saline, which is the normal salinity point of body fluids, not “9% saline” [sic] which hypertonic level will do serious harm, if you could even find it.)
    BLUF: Decimal points: still an actual thing that matters in science and medicine.
    Typos happen. That one needs fixing, STAT.

    Other than that, it’s a pretty decent overview.
    FYI, the treatment for those donating a pint (+/- 500ml) of whole blood at the Red Cross is to give a glass of orange juice, and a cookie, for the last twenty years or so.
    Yes, really.
    So don’t freak about blood less of that amount or less – from normal-sized adults. Beyond that point, or in smaller patients, things get more serious.

    When transfusing whole blood, the unit (the +/- 500ml bag) should not be infused in less than 2 hours, nor more than four.
    If you give it faster than 2 hours, and there’s an adverse allergic transfusion reaction, you’ll have dumped too much allergen into the system of an already unstable patient, and probably kill them.
    Let’s not do that.
    If you take over 4 hours to administer the same unit, it will clot more, and you risk things like pulmonary embolism, heart attack, and stroke.
    Let’s not do that either.
    The first 15 minutes should be done more slowly, because if you’re gong to get a reaction, it will probably happen within those first 15 minutes.

    You need a baseline temperature, pulse, and blood pressure before giving the blood product. Then repeat it at 15 minutes after starting, then at +1, +2, +3 hours from start, and after completion in 4 hours or less.
    A notable increase (>1° F.) in temperature or pulse(>10%), or a notable drop (>10%) in blood pressure is a sign of possible transfusion reaction. That means 10 beats in a pulse rate of 100, or 10 points for a 100 point blood pressure, etc.

    Pre-medicating with acetaminophen and Benadryl as indicated will probably prevent this in some cases with minimal complications.
    In a mild reaction, you may still be able to give the blood but at a slower rate (yet still within that 4-hour maximum time limit.)
    FWIW, in hospital, I calculate my admin time to be as close to 2 hours as possible, so that if I need to slow things down, I can cut the rate in half, and still be done in <4 hours. That's how you do it if you want to succeed and minimize problems.

    Major problems are an anaphylactic transfusion reaction.
    During the transfusion, stay alert for signs and symptoms of a reaction, such as
    fever or chills,
    flank (kidney) pain,
    vital sign changes (see above),
    urticaria (i.e. "hives", a bumpy red rash),
    dyspnea (difficult/painful respirations),
    and bronchospasm (spasm of bronchial smooth muscle producing narrowing of the bronchi) which presents for you as wheezing, gasping, or complaints of feeling short of breath.

    Optimal management of reactions begins with a standardized protocol for monitoring and documenting vital signs. (See above)
    Obtain and chart the patient’s vital signs before, during, and after the transfusion.

    If you suspect a transfusion reaction, take these immediate actions:
    •Stop the transfusion.
    •Keep the I.V. line open with normal saline solution.
    •Notify higher medical authority, as possible.
    •Intervene for signs and symptoms as appropriate.
    •Monitor the patient’s vital signs.

    If you watch (like a hawk!) for signs of a reaction, and intervene immediately, the consequences can stay minor.
    In unstable patients with life-threatening injury, especially those unable to communicate rapidly and clearly, you’d better be watching WTF is going on, and not depending on them to tell you something, because they may not be able to do so.

    If you can’t do that, you shouldn’t even be considering a field transfusion, nor any other kind.

    And I don’t care what you saw in Shooter Rambo XI or some straight-to-cable TV movie horseshit: you won’t be doing this with turkey basting needles sterilized with Zippo lighters, and surgical tubing you found in the bargain bin at Hardware World.

    As even the article linked makes clear, you need the right toys to play the game.

    • And as a reminder/PSA, you do have these little beauties printed and laminated in all your kits, and with all your medics and potential medics, right?

  4. Johnny Paratrooper

    5,000 GSW’s to the legs in one surge of weekly protests.

    FUSA will be the same.

    If you live outside of a major city, you are on the modern frontline.

    Plan, and act, accordingly.

    Remember, leg shots evacuate themselves from the field. Every revolutionary wants to look like a fierce warrior but leave the field ASAP.

    A comrade going down is a perfect excuse to pack them up and clear the field.

    Crowds of anonymous comrades will abandon their dead.

    One should consider letting vermin remove their own.
    Or you will be forced to do it.

    • I’d only add that I don’t start getting itchy to transfuse a HEALTHY adult patient until EBL reaches 1200-1700mL’s- depending on the size of the patient. Even that just means that I’m taking the steps to set it up, not necessarily hanging it- all depends on clinical signs and symptoms.
      100mL’s of blood is gonna look like a lot of blood on clothes with some on the floor. 500 mL’s is gonna look like a shitload of blood and your gonna notice the smell. 1000 mL’s looks like a slaughterhouse and you’ll have pools of clotted blood on the floor. Fairly healthy people can loose a lot of blood with no real term problems. But that also depends on the how and why. I myself am a big fan of everyone doing everything they can to keep the red stuff on the inside.