Page 137 - JSOM Summer 2019

The evaluating medic performed a MARCH examination. A FIGURE 1 Field improvised autologous transfusion (FIAT) kit.
right upper extremity entrance wound was noted. External 1, Chinook Field Blood Transfusion Kit (TMM-FBTK); 2, chest tube;
hemorrhage was controlled, and airway was intact. He had 3, five-in-one tubing connector (or Heimlich valve); 4, 60mL syringe
decreased breath sounds on the right. He had bilateral palpa- with LuerLoc (can use 20 or 40mL); 5, three-way stop-cock; 6, Cook
pneumothorax set connector tubing (can use standard IV tubing set
ble radial pulses, and intravenous (IV) access was established. if not available).
Initial vital signs on presentation were heart rate 145 bpm,
blood pressure 124/76mmHg (mean arterial pressure [MAP]
92mmHg), and an O saturation of 95% on room air. The
2
eFAST examination revealed no intraperitoneal fluid and ab-
sent lung sliding in his right thorax.
Based on these findings, a chest tube was inserted. Immedi-
ate blood return of 700mL was noted. The chest tube was
clamped briefly until a Pleurovac (Atrium Oasis Dry Suc-
tion Water Seal Chest Drain model 3600) and suction could
be connected. Immediately, an additional 400mL of blood
drained, and his blood pressure dropped to 86/50mmHg
(MAP 62mmHg). One unit of low-titer, type O whole blood
(LTOWB) was warmed and administered. The surgical team
took the patient to the operating room (OR), where he was
given another unit of LTOWB and 250mL albumin 5%. In
the OR, a median sternotomy was performed, and a bleeding
tract along the posterior right lower lobe and a fissure was
repaired. The patient survived his damage control surgery and
was evacuated by local national helicopter to a coalition Role
2 facility, where he survived until discharge to a local national Bilateral IV access was established and the patient underwent
facility a few days later. rapid sequence intubation with 20mg ketamine, 2mg Versed,
and 100mg of succinylcholine. A chest tube was placed con-
Surprisingly after hundreds of patients, this was the first mas- currently. On insertion of the chest tube, it was noticed the
sive hemothorax that was encountered during the deployment. patient had a hemothorax. The chest tube was immediately
The team recognized that a gap existed for the ability to collect clamped while the AT system could be assembled. The FIAT
a patient’s exsanguinated blood and reinfuse safely. No com- technique was initiated as described in Table 2. Once the kit was
mercially designed products were available for this purpose assembled, the hemothorax was evacuated into the blood do-
due to the austere location, slow supply system, and improper nation bag exactly as intended (Figure 2). Ultimately, however,
ordering by the unit’s logistical component before deployment. only approximately 300mL of blood was evacuated from the
As predominantly ground medics who worked out of a single hemothorax. Due to concerns of citrate toxicity, stabilization of
assault aid bag, the team thought it was advantageous to be vital signs with initial whole blood transfusion, and a negative
able to perform an autotransfusion with items commonly car- eFAST reassessment, the decision was made not to autotrans-
ried for other purposes. fuse the blood. Though not used for treatment, the FIAT proce-
dure provided important diagnostic information, as the medics
During predeployment training in North Carolina, the team now knew that only 300mL of shed blood was in the thorax.
had learned to create a field improvised ATkit using a Chinook We applied a hypothermia prevention kit to the patient, and
Field Blood Transfusion Kit (TMM-FBTK), chest tube, five- he was transferred by ground to a partner force Role 2 facility.
in-one tubing connector (or Heimlich valve), 60mL syringe
with LuerLoc, three-way stop cock, Cook pneumothorax set
connector tubing, and standard filtered blood administration TABLE 2 Field Improvised Autologous Transfusion (FIAT)
Technique
tubing (Figure 1). The team used the basic technique but ex-
changed a Heimlich valve for the five-in-one connector and an 1. Prepare collection kit.
intravenous (IV) drip set in place of the Cook pneumothorax a. Blood collection bag
connector. The IV drip chamber fits snugly inside a standard b. Cut collection tubing 12 to 18 inches from collection bag
Heimlich valve that can be wrapped in electrical tape to seal c. Three-way stop-cock
against leaks. i. Attach to end of blood collection tubing.
ii. Attach 20 to 60mL syringe with LuerLoc.
Casualty 2 (FIAT kit): A second partner force Soldier sustained iii. Attach connecting tube from Cook pneumothorax set .
a GSW to the left chest during combat operations. Time from 2. Attach connecting tube from Cook pneumothorax set to five-in-
point of injury to CCP was unknown but estimated at less one adapter (or Heimlich valve).
than 60 minutes. The evaluating medic performed a MARCH 3. Insert chest tube in standard fashion.
examination. There was no obvious extremity hemorrhage, 4. Connect five-in-one connector to chest tube.
the airway had no trauma, there was a penetrating wound to
the left chest, and breath sounds were diminished on the left. 5. Using standard technique with the three-way stop-cock, use the
syringe to gently draw out intrathoracic blood and then transfer
The casualty had rapid, thready radial pulses. Initial vital signs to the blood donor bag.
were heart rate 129 bpm, blood pressure 108/82mmHg (MAP 6. Once 450mL is collected, the AT blood can be transfused using
90mmHg), and O saturation of 85%. His Glasgow Coma the standard blood administration component of the TMM-
2
Scale score was E = 2, M = 4, V = 2; total 8. FBTK (ensure use of filtered line).
Novel Field Improvised Autologous Transfusion | 135