In October 2018 I was lucky enough to attend the Emergency Nurses Association conference in Pittsburgh, PA. By FAR my favorite session there was Assassinations Throughout History: Would They Survive Today, originally given by Joseph Blansfield. As a trauma junkie, the idea that modern medicine has evolved to a place where even some of the most deadly assassinations could actually be saved peaked my interest. The injuries sustained by the following well-known men rendered them dead at the time of their occurrence. But if they were injured in the exact same manner today…could we save them?
Julius Caesar:
Hemorrhagic shock and Mass Blood Transfusions
“No one is so brave that he is not disturbed by something unexpected.” – Julius Caesar
Julius Caesar was born in 100 BC in Rome, Italy where he rose to power as the historical figure he eventually became. Caesar was a military general and politician who played a huge role in the end of the Roman Republic followed by the rise of the Roman Empire. Although Caesar was warned not to attend a meeting with the Senate by multiple sources claiming he was being conspired against, he showed up anyways. On the Ides of March [March 15th, 44 BC], he was attacked by many members of the Senate leaving him with 23 stab wounds across his body. It is thought that the lethal injury came from a sole stab wound to the chest. Julius Caesar was the first documented autopsy on record; he was then cremated.
Mechanism of Injury: 23 stab wounds including 1 to the chest cavity
Cause of Death: Hemorrhagic shock (this is when blood loss becomes so severe that cellular destruction occurs due to a lack of oxygen being delivered to them). Perfusion is the act of administering oxygen to cells so they can function properly and the goal of all trauma [and medical] care is to INCREASE PERFUSION (Hey nurses: this is why lactic acid levels are so important in trauma care!)
Would he live or die today?: LIVE
Why?: Today there are many advances to the mass [blood] transfusion protocols in emergency departments, especially those in designated trauma centers, that can reverse hemorrhagic shock and save trauma victims’ lives. The standard for a transfusion to be considered a “mass” transfusion is 3 units of blood products being administered within 1 hour. [The old definition was 10 units administered within 24 hours]
There are 4 components of blood:
-plasma (the liquid part of blood in which red cells, white cells and
platelets are suspended)
-red blood cells (transports oxygen)
-white blood cells (fights infection)
-platelets (clots blood)
It makes sense then that when you administer blood products, they are packaged as fresh frozen plasma, packed red blood cells or platelets; all separated from each other so they can most effectively do what you want them to do within the recipients body. Occasionally whole blood is administered that still has everything mixed together but this is rare and not as helpful. Fresh frozen plasma (also called FFP) and platelets are yellow in color, whereas the packed red blood cells are the rich deep crimson color you would imagine a bag of blood to look like. White blood cells are not given as an infusion.
Fact: O negative blood is considered the “universal donor” and is the blood type given in emergent trauma settings when the patients blood type is unknown
There are a lot of factors that come into play when administering blood products so you don’t cause more harm than good. Obviously the initial goal for a patient in hemorrhagic shock is to simply save their life, you have to consider the long term effects and eventual outcome your interventions may cause. It is recommended that blood products be given in a 1:1:1 ratio, meaning for every unit of red blood cells given, 1 unit of platelets and 1 unit of plasma should also be administered. It is recommended to give plasma and platelets FIRST when possible.
By following the recommended “rules” of mass transfusion guidelines, you avoid the dreaded triad of death. Although it is beyond the scope of this particular article, metabolic acidosis (an imbalance of the pH level of the body), coagulopathy (impaired ability to clot blood) and hypothermia (being too cold) are the three leading causes of poor outcomes in a trauma situation. Once one of these things occur it is very difficult to reverse and a cascade effect usually occurs. That is why as trauma nurses we are extremely concerned about keeping trauma patients WARM whether with heated blankets, heated IV fluids/blood products, keeping the trauma bay at a certain temperature, or a combination of all of these. This means all those blood products you’re giving should be put through a warmer prior to administering; giving room temperature fluids will RAPIDLY lower a patients core body temperature and can push them into the triad of death.
Remember: hypothermia AND acidosis stops your blood from being able to clot normally…seems like a big problem when someone is bleeding to death, yeah? This can lead to a WICKED complication called DIC (disseminated intravascular coagulation) where you basically just uncontrollably bleed out of every hole in your body. Graphic. Bottom line: follow best practice guidelines for mass transfusion protocols and keep your patient toasty!!
Curious travels <3