13-8

Blood Products and Medications Affecting Blood

• Adults have about 5 liters of blood, 7-8% of body weight.
• Trauma or medical conditions can alter blood amount, composition, or performance.
• Blood components are type-specific.
• Mismatched blood transfusions can cause adverse reactions.
• Cross-matching is crucial in hospitals to decrease transfusion reaction risk.
• Cross-matching requires blood sample analysis before administration.
• Unmatched blood, usually type O Rh-negative, is theoretically safe for all types in emergencies.
• Paramedics may decide blood type during interfacility transport, consulting medical control if unsure so seek online Med control.

Low Titer Group O Whole Blood

• Collected from a single donor and tested for specific immunoglobulin levels.
• Advantages: rapid administration, fewer additives/anticoagulants, reduces human error.
• Disadvantage: short shelf life.
• Requires careful monitoring during administration (pulse rate, blood pressure, temperature).
• Monitor indwelling urinary catheters for urine color changes.
• In emergency rooms, nurses monitor for 15 minutes during and after blood infusion for reactions.
• Special filtered IV tubing is needed for most blood products.
• Normal saline is the preferred IV fluid for Y-site tubing administration after transfusion.

Packed Red Blood Cells (RBCs)

• Correct anemia from blood loss, inadequate RBC production, or hemolysis.
• Administration rate should match blood cell loss rate.
• One unit contains preservatives and 225-250 mL of concentrated RBCs.
• One unit increases hematocrit by about 3%.
• Children and infants require patient-specific volume administration.
• Patients at risk for volume overload need slow administration and monitoring.
• Administer over no more than 4 hours per unit.
• Can be rapidly administered with commercial pressure infusers or pressure bags.
• Use the largest IV possible; at least 20 gauge (preferably 18 or larger) in adults.
• Trauma and hemorrhage patients need adequate IV fluid resuscitation before or during RBC administration.
• AB is the universal recipient, O is the universal donor.
• Citrate-based preservatives can cause hypocalcemia (citrate binds with calcium).
• Patients are also at risk for hyperkalemia.

Fresh Frozen Plasma (FFP)

• Treats impaired blood clotting after trauma, major hemorrhage, warfarin toxicity.
• Used when giving large volumes of other blood components.
• Compatibility with the patient’s blood type is required, but not necessarily RH compatibility.
• Same volume in units as packed RBCs.
• Requires adequate defrosting before administration.

Cryoprecipitate

• Contains a concentrated assortment of blood clotting factors without the additional volume present in FFP.

Platelets

• Correct thrombocytopenia from trauma, hemorrhage, chronic conditions, or anticoagulant medications.
• Must be blood type and Rh compatible.

Medications Altering Blood Performance

• Blood platelets and coagulation chemicals stop bleeding, forming a thrombus.
• Some medications alter blood’s ability to form a thrombus.

Tranexamic Acid (TXA)

• Promotes blood clotting and reduces mortality in trauma patients with severe bleeding.
• Blood clot formation may be coupled with hyperfibrinolysis, dissolving new clots.
• TXA is a commercial preparation of lysine which prevents fibrin clot breakdown.
• Significantly decreases mortality if given within 3 hours of the traumatic event.
• Initially used for OB patients, later found effective for trauma.

Anticoagulant Medications

• Impair the function of clotting or coagulation chemicals in the bloodstream.
• Enhance the function of substances in the bloodstream that inhibit clot formation.
• Heparin and enoxaparin (Lovenox) enhance antithrombin III to inhibit blood coagulation.
• Used to treat or prevent acute coronary syndrome, deep vein thrombosis, and pulmonary embolism.
• Compatibility issues with heparin and nitroglycerin, potential for bleeding.

Warfarin

• Common anticoagulant for treating or preventing blood clots.
• Prevents the production of four blood clotting factors using vitamin K.
• Patients at risk of life-threatening bleeding if warfarin levels are not controlled.
• Trauma or hemorrhage can increase effects.
• Certain foods, alcohol, and medications can increase warfarin effects.
• Warfarin levels are inferred by blood prothrombin time (PT) and INR levels.
• Treatment options available for severe bleeding or emergency surgery.
• Warfarin can be reversed, but providers attempt to control bleeding first.

Antiplatelet Medications

• Reduce platelet aggregation to prevent new thrombus or extension of existing thrombus.
• Aspirin is used with ACS, indicated for stroke treatment once hemorrhage is excluded.
• Possibility of aneurysm complications.
• Rapidly eliminated, but effects last up to 10 days until platelets are replaced.
• Clopidogrel (Plavix) and ticlopidine are oral medications that also inhibit platelet aggregation.
• Clopidogrel is superior to aspirin, while ticlopidine has several adverse effects.
• Glycoprotein IIb/IIIa inhibitors provide potent platelet inhibition via IV.
• Adverse effects include bleeding and thrombocytopenia in 5-7% of patients.

Fibrinolytics

• Dissolve blood clots in arteries and veins.
• Administered for emergency treatment of MIs and strokes.
• Lower doses can open occluded vascular catheters.
• Can cause life-threatening hemorrhage.
• Not for use in trauma or surgery patients.
• Many absolute and relative contraindications.
• Avoid multiple IV attempts to minimize unnecessary trauma.
• Long prehospital time may preclude administration of fibrinolytics.

Medications Used for Neurologic Conditions

• Opiate or narcotic medications act as analgesics.
• Naloxone (Narcan) is a powerful reversal agent.
• Benzodiazepines treat persistent seizures, sedation, and anxiety.

Opiate Analgesic Medications

• Stimulate opiate receptors to relieve or prevent pain.
• Suppress cough reflex.
• Tolerance, cross-tolerance, and addiction are known issues.
• Long-term users require higher doses for pain relief and may experience withdrawal if reversed.
• Can cause profound sedation, respiratory depression, and apnea with excessive doses.
• Other adverse effects: hypotension, bradycardia, palpitations, dysrhythmias, non-cardiogenic pulmonary edema.

Morphine Sulfate

• Frequently used in EMS.
• Can cause nausea/vomiting in up to 60% of patients so caution with patients with airway compromise.
• May produce histamine release causing itching, flushing, and diaphoresis.

Fentanyl

• Generally less prone to cause hypotension.
• Does not have the same risk of nausea and histamine release as morphine.
• Can be administered intranasally

Naloxone (Narcan)

• Opiate antagonist medication used to reverse effects of excessive opiate chemicals.
• Causes complete or partial reversal of clinical effects.
• Efficacy is dose-dependent; large doses are often required.
• Shorter duration than many opiate chemicals, so repeated administration or continuous IV infusion may be needed.
• Administer enough to correct life-threatening conditions to avoid severe withdrawal symptoms.

Phenytoin and Keppra

• Administered to prevent seizure activity.
• Can be received on a long-term basis.
• Used for interfacility transport of patients with head injury, cerebral hemorrhage, or status epilepticus.
• Decrease seizure potential by altering sodium channels, limiting cellular sodium entry into the central nervous system.