At this point, it is appropriate to begin red cell transfusions, particularly if blood loss has not been controlled. If the patient appears to be stable, it usually is possible to wait for fully cross-matched blood, but that decision must be individualized, based on the assessment of ongoing blood loss and the efficiency of the local blood bank. When in doubt, it is advisable to use type-specific blood. Several studies have shown this to be a very safe practice, and delays in providing needed oxygen-carrying capacity are potentially more harmful to the patient. Early blood therapy is particularly important in the elderly and in those with significant respiratory and cardiac disease, as their ability to tolerate a decrease in oxygen-carrying capacity is significantly reduced.
More aggressive therapy is mandated in the hemorrhaging patient exhibiting any degree of hemodynamic instability or signs of end-organ hypoperfusion. These patients almost always require blood transfusions, and it is appropriate to begin type-specific blood early unless there is a prompt and persistent improvement in perfusion with saline solution alone. Type-specific blood is indicated in patients who are profoundly hypotensive on initial presentation, those who remain in shock after crystalloid infusion, and those who demonstrate rapid ongoing hemorrhage. Continued administration of crystalloid without blood may result in profound dilution of the remaining red blood cell mass, platelets, and coagulation factors. It may also disrupt clot formation in the injured vessels. Volume restored at the expense of oxygen-carrying capacity and hemostasis is of questionable therapeutic value.
The moribund patient requires even more prompt restoration of circulating red blood cell mass. In this case, type O blood should be used immediately if it is available. Type O Rh-negative blood should be given to females of childbearing age. In most other situations Type O Rh-positive blood is preferred because of its greater availability. A sample for type and cross match should always be drawn and sent before administration of type O blood.
Autologous whole blood may be given if the hemorrhage is intrathoracic and the capabilities for autotransfusion exist ( Fig 27.-1). Autotransfusion decreases the risk of transmission of diseases such as acquired immunodeficiency syndrome (AIDS) and hepatitis, and it also decreases the demand on the blood bank. There has been some discussion concerning autotransfusion in patients with intraabdominal injuries. It can be difficult to determine, especially in the ED, if there is fecal contamination of intraabdominal blood. Transfusion of contaminated blood has not been shown to be safe, and it may be prudent to autotransfuse blood from intraabdominal injuries only in the operating suite, after the source of blood has been discovered and the risk of transfusing contaminated blood is known.
FIG. 27-1. Collection apparatus. A, anticoagulant volume control burette; B, chest tube; C, latex drainage tubing; D, male-to-male connector; E, end of drainage tubing with side port; F, inlet port of red liner cap attached to collection canister; G, collection liner bag; H, downstream suction hose; J, liner lid tubing connector; K, canister tee; and N, liner stem with protective cap. Abbreviation: CPD, citrate phosphate dextrose. [From Roberts JR, Hedges JR (eds): Clinical Procedures in Emergency Medicine, 2d ed. Philadelphia, Saunders, 1991, p 412, with permission.]
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