Page 31 - Journal of Special Operations Medicine - Fall 2014

capabilities of most prehospital trauma systems and combat medics in order to execute this protocol safely in
providers. The prehospital administration of whole the is the ability to reliably identify casualties who will
blood and/or blood components has now been proven benefit from whole blood transfusion. 63
feasible but requires meticulous attention to detail to ac-
complish safely. Crystalloids and Colloids—General
The best crystalloid or colloid fluid for resuscitation
In order to administer whole blood or blood compo- from hemorrhagic shock when blood products are not
nent therapy safely and effectively, a command- or available is a topic of controversy. 15,30 Large volumes of
theater-approved protocol that has been coordinated crystalloid or colloid fluid administered in the prehospi-
with the appropriate blood banking facilities should be tal setting are associated with worsening of the coagu-
used. All medical personnel who will be responsible for lation profile on arrival at the emergency department.
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administering blood products in the prehospital combat Resuscitation with large volumes of either crystalloids or
setting should be trained in the approved protocol. colloids contributes substantially to trauma-associated
coagulopathy. The presence of a coagulopathy was
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The details of the protocol may vary depending on the found to nearly double the mortality in patients with
maturity of the theater, service guidelines, the specific traumatic subdural hematoma. 125
tactical scenarios envisioned, and the blood-banking lo-
gistics in the area of operations. In general, the follow- The CRISTAL multicenter, randomized clinical trial
ing items should be addressed: compared resuscitation with colloids versus crystalloids
in 2857 consecutive intensive care unit patients with
• Training of combat medical personnel in the approved shock from sepsis, trauma, or other causes. Worthy of
protocol note is that trauma patients comprised only 1.6% of the
• Documentation of this training colloid group and 2.5% of the crystalloid group. The
• Maintenance training interval choice and volumes of crystalloid or colloid was based
• Which blood products will be used (RBCs, FFP, etc.) on the standard practice at each of the 57 participat-
• Ratio of plasma and platelets to RBC units infused ing hospitals. Crystalloids included isotonic saline or
• ABO and Rh compatibility issues HTS and any buffered solutions. Colloids included both
• Screening of potential donors hypo-oncotic (e.g., gelatins, 4% or 5% albumin) and
• Transport container to be used hyper-oncotic (e.g., dextrans, hydroxyethyl starches
• Transport container handling instructions [HESs], and 20% or 25% albumin). The dose of HES
• Storage temperature requirements used could not exceed 30 mL per kg of body weight per
• Storage temperature documentation requirements day. There was no difference in mortality at 28 days, but
• Disposition of unused units on return of containers patients treated with colloids had improved survival at
• Maximum time allowed for transport in a container 90 days (34.2% versus 30.7%, p = .03). The authors
127
• Number and types of units to be transported also noted that there was no increase in renal replace-
• Indications for transfusion ment therapy associated with colloid use.
• Procedure for transfusion
• Equipment required Colloids—General
• Pretransfusion check of units Colloids are more effective than crystalloids for ex-
• Protective equipment required panding the plasma volume because they contain large,
• Transfusion rate poorly diffusible solute molecules that create an osmotic
• Transfusion pressure pressure to keep water in the vascular space. Animal
128
• Warming of units models have shown that retention of a synthetic colloid
• Walking blood bank procedures for fresh whole blood (Voluven) in the intravascular space resulted in less ex-
• Prescreening for walking blood bank donors travasation of fluid into the lung than LR with a result-
• Postdonation procedures ing improvement in oxygenation. 129
• Minimum time between blood donations
• Monitoring during transfusion Colloids include both human albumin solution and
• End points of resuscitation synthetic colloids. The most commonly used synthetic
• Management of transfusion reactions colloid is HES. There are significant variations in the
• Documentation of transfusion 13 composition and properties of HESs. Hextend has a
mean molecular weight of approximately 670,000Da
Protocols have been developed for use by Special Op- (range 450,000 to 800,000Da) and a molar substitution
erations units to help facilitate the use of whole blood of approximately 0.75 (an average of approximately 75
in the far-forward combat environment. Strandenes and hydroxyethyl groups per 100 glucose units). The HES
his colleagues note that the most critical skill required of molecules in Hextend are formulated in a balanced

Fluid Resuscitation for Hemorrhagic Shock in TCCC 23