29.5 Circulation Flashcards
Which gender can receive either O positive or O negative blood at any time
Males
Females of childbearing age receive what type of whole blood (unless it is a matter of life and death)
O negative
Which class of hemorrhagic shock:
30% of blood loss
1)1500-2000 ml of blood loss
2)> 120 pulse rate per minute
3)Decreased blood pressure
4)30-40 respirations per minute
5)Urine output 5-15 ml per hour
6)Level of Consciousness exhibiting confused demeanor
Class III
Which class of hemorrhagic shock:
> 40% of blood loss
1)> 2000 ml of blood loss
2)> 140 pulse rate per minute
3)Decreased blood pressure
4)> 35 respirations per minute
5)Urine output negligible
6)Level of Consciousness exhibiting lethargic demeanor
Absent radial pulse/systolic blood pressure below 80mmHg
Class IV
Indications for transfusion
- Hemorrhagic shock
- Evidence of severe bleeding to a non-compressible or difficult to compress area with hypotensive patient
What is a potentially life-threatening reaction caused by acute intravascular hemolysis of transfused red blood cells
Hemolytic Reactions
Signs of Hemolytic Reactions
1)Fever
2)Chills
3)Flank pain
4)Oozing from intravenous sites
Treatment of hemolytic reactions
Involves aggressive hydration and diuresis (to prevent kidney damage from lysed RBC elements
Treatment of anaphylaxis reaction from transfusion
Treatment is just like any other anaphylaxis with IM Epinephrine, Antihistamines, and vasopressors, depending on the degree of allergic symptoms
How much blood can a liver process without additional calcium
13 units worth of FWB
Treatment of citrate toxicity from transfusion
Recommendation though is to give 1 amp of Calcium Gluconate every 4 units of FWB to avoid toxicity and hypocalcemia
The most common cause of Febrile non-hemolytic transfusion reactions is due to
release of cytokines from white blood cells
What is the difference between urticarial reaction and anaphylaxis reaction from transfusion
Urticarial reaction are associated with hives but no other allergic findings(wheezing, angioedema, and hypotension).
IMMEDIATE ACTIONS (ALL PATIENTS) that develop an acute transfusion reaction should follow these steps:
(a)Immediately stop the transfusion
(b)Maintain a patent intravenous/intraosseous line, start fluid bolus withbalanced crystalloid
(c)Assess the patient, including symptoms of fever, respiratory distress, chest pain,back pain, itching, angioedema
(d)Measure vital signs and perform physical examination guided by symptoms
(e)Confirm the correct product was transfused to the intended patient and correct blood type of the donor
(f)Contact your supervising physician to discuss the appropriate evaluation and initial management as soon as the tactical situation allows
(g)Pass all the information to the next echelon of care
Blood should be drawn into an unexpired, intact commercial single unit whole blood collection bag with what capacity
capacity containing 63 ml of CPD or CPDA-1anticoagulant.
How much blood should be drawn for 1 unit of FWB
450ml
When should collected blood be transfused
Immediately and within 24 hours
What should be done for unused FWB
Reinfused into the donor
How often should you record vitals after blood transfusion
minimum every 15 minutes. For the first 15 minutes of the transfusion record them every 5 minutes.
What is the risk of used LR to prep line for blood transfusion
hemolysis or precipitate forming
Flow rate for blood transfusion
Set the flow rate to deliver approximately 10-30ml of blood over the first 15minutes (1gtt/4-6 sec = 1ml/min). * NOT Necessary if pre-collected O LowTiter from pre-screened individuals
How often should you re-check vitals for blood transfusion
- Monitor the vital signs every 5 minutes for the first 15 minutes and observe the casualty for indications of an adverse reaction.
- After the first 15 minutes and there is no adverse reaction evident set the main roller clamp to deliver approximately 200ml/min (1 Unit (U) in 2-2.5minutes).
What forms do you document blood transfusion
Document the procedure on the SF 518 and SF 600 or patient AAR and forward to the Role III hospital in country
If a casualty is anticipated to need a significant volume of blood transfusion due tothe following:
(a)Hemorrhagic Shock
(b)One or more amputations
(c)Penetrating torso trauma
(d)Evidence of sever bleeding
What should be given?
Tranexamic Acid (TXA)
Administration of TXA
(1) Survival benefit is greatest when TXA is given within 1 hour of injury.
(2) The greatest decrease in blood loss is seen when TXA is started ASAP!
(3) Administer 1 gram of tranexamic acid in 100 ml normal saline or lactated ringers as soon as possible, but not later than 3 hours after injury.
(4) When administering TXA is should be administered over 10 minutes.
(5) A second infusion of 1 gram TXA may be administered after initial fluid resuscitation has been completed.
Reasons for IV Administration
(a)Maintenance therapy- replaces normal ongoing losses.
(b)Replacement therapy - corrects any existing water and electrolyte deficits.
(c)Correlation with cognitive function and/or urine output is often a better indication of adequate perfusion
Types of IV solutions
(a)Colloids
(b)Crystalloids (Isotonic, Hypotonic, Hypertonic)
(c)Blood and blood products
Which IV fluid is used to increase the blood volume following severe loss of blood (hemorrhage)or loss of plasma (severe burns)?
Colloids (Volume Expanders)
Which IV fluid does the following:
(a)Fluids that consist of water and dissolved crystals, such as salts and sugar.
(b)Used as maintenance fluids to correct body fluids and electrolyte deficit.
Crystalloids
What do crystalloids contain
electrolytes (e.g., sodium, potassium, calcium, chloride) but lack the large proteins and molecules found in colloids
The most common isotonic solutions are:
a)Lactated Ringers (LR) (which contain sodium chloride, potassium, calcium and lactate)
b)Normal Saline Solution (NSS) (0.9% sodium chloride solution)
c)5% Dextrose in water (D5W)
What is a hypertonic solution
If a crystalloid contains more electrolytes than the body plasma, it is more concentrated and referred to as “hypertonic”
Uses of Normal Saline Solution (NSS)
a)Shock
b)Resuscitation
c)Fluid challenges
d)Blood transfusions
e)Metabolic alkalosis
f)Hyponatremia
g)DKA
Uses for LR
a)Dehydration
b)Burns
c)GI tract fluid loss
d)Acute blood loss
e)Hypovolemia
Uses for D5W
a)Fluid loss and dehydration
b)Hypernatremia
This is the most common intravenous access method in both hospital and field settings
Peripheral IV catheter
A form of intravenous access that can be used for a prolonged period of time (e.g. for long chemotherapy regiments, extended antibiotic therapy, or total parenteral nutrition).
peripherally inserted central catheter (PICC or PIC line)
An infusion tube located in or near the heart, which is at the center of the circulatory system. For example, a Triple Lumen catheter with its tip in the right atrium is a central line.
Central Line
the process of injecting directly into the marrow ofa bone to provide a non-collapsible entry point into the systemic venous system
Intraosseous infusion (IO)
Intravenous Infusion Methods
(1) IV Bolus/IV Push
(2) Intermittent infusion
(3) Continuous drip infusion
IO infusion is limited to how long
to a few hours until intravenous access is achieved.
When is IO indicated
during traumatic situations when attempts at venous access fail (three attempts or 90 seconds) or in cases where it is likely to fail, and speed is of the essence.
Intraosseous (IO) Contra-indications
(1) Ipsilateral fracture or crush injury of an extremity (increases the risk of subcutaneous extravasation, so another extremity should be used)
(2) Previous orthopedic procedure near the selected insertion site
(3) Previous IOVA attempts in the same bone (even if IOVA was obtained, fluid would leak out of the previously attempted site)
(4) Infection at the selected insertion site
(5)Inability to locate landmarks (e.g., excessive tissue over the insertion site
(6) Brittle bones (e.g., osteogenesis imperfect or anything increasing risk of fracture)
Where is the location for IO in the tibia
Palpate the tibial tuberosity. The site for cannulation lies 1-3 cm below this tuberosity on the anteromedial surface of the tibia
Complications from IO
(1) Important complications are tibial fracture, especially in small framed people.
(2) Compartment Syndrome
(3) Osteomyelitis
(4) Skin Necrosis
Analgesics in TCCC Combat Wound Medication Pack (CWMP)
- Tylenol 625 mg bilayer caplet, 2 tablets PO every 8 hours. Max of 4 gram over a 24-hour period
- Meloxicam 7.5 to 15 mg PO daily
Pain management for:
(1) Moderate to severe pain
(2) Casualty IS NOT in shock or respiratory distress and casualty is NOT at significant risk ofdeveloping either.
- Oral Transmucosal Fentanyl Citrate (OTFC) 800 mg. Place between cheek and the gum, instruct the patient to not chew.
Pain management for:
(1) Moderate to severe pain
(2) Casualty IS in shock or respiratory distress OR casualty is at significant RISK of either developing either condition.
- Ketamine 50 mg IM or IN (Intranasal) with repeat dose every 30 minutes or 20mg IV or IO with repeat dose every 20 minutes. *note: end point is control of pain or development of nystagmus
- Morphine 5mg IV/IO. Max of 15 mg. Reassess in 10 minutes and repeat as necessary to control severe pain. Ensure to monitor for respiratory depression.
TCCC Antibiotic Recommendations:
- Moxifloxacin (Avelox)- 400 mg IV/PO q 24 hours
- Ertapenem (Invanz) 1-gram IV q24 hours
- Levofloxacin (Levaquin) 750 mg IV/PO q24 hours
- Cefazolin (Ancef, Kefzol) 1 gram IV every 8 hours for 7 days
- Ceftriaxone (Rocephin) 2 grams IV every 12 hours
