Trauma is the leading cause of death in children and adults under 44 years of age.1 Exsanguination plays a significant role in as many as half of these deaths, most commonly after the patient reaches the hospital and within the first 24 hours after injury.2 Hemorrhagic shock is a primary indication for the transfusion of homologous blood products. Transfusions with homologous blood products carry the possibility of associated complications including transfusion reactions, transmission of infectious diseases, and sensitization to antigens.3 Massive transfusions are associated with the additional complications of acidosis, dilutional coagulopathy, and hypothermia. Transfusion of homologous blood products in the trauma patient has been independently associated with an increase in both morbidity and mortality, particularly when transfusing older, stored blood products.4–6 Blood centers have more than doubled the prices of blood products in recent years due to a decline in blood donors, higher skilled labor costs, and increases in the cost of testing and processing blood.7
Alternative transfusion strategies have been developed for elective surgeries. These include autologous (acute) normovolemic hemodilution, autologous preoperative donation, and intraoperative cell salvage with autotransfusion. The first two are not possible in the acute Emergency Department setting. Cell salvage with autotransfusion represents a viable alternative to autologous transfusion in the Emergency Department, but has received limited attention in the trauma patient.
In the trauma setting, an autotransfusion was first performed by Elmendorf during the First World War on a soldier with a traumatic hemothorax.8 It was subsequently used sporadically as a life-saving procedure.9 A modified autotransfusion for a traumatic hemothorax was described in 1978.10 This technique was simple, safe, and easy to practice. It was used in approximately 400 patients with a traumatic hemothorax without any noticeable complications. This technique is still applicable to current practice.
Many of the patients with a life-threatening hemothorax either die before reaching the Emergency Department or experience severe hemodilution that accounts for some deaths in the Emergency Department and the Operating Room. Since hypovolemic shock secondary to trauma is the most frequent indication for a massive blood transfusion in the Emergency Department, it is therefore an indication for an autotransfusion. Much of the controversy surrounding practice paradigms centers on the disagreement as to what constitutes the proverbial perfect procedure.
An autotransfusion may occur in the Emergency Department, Operating Room, and Surgical ICU with increasing frequency. In this procedure, the shed blood is collected, mixed with an anticoagulant, concentrated, washed or filtered, and then returned through an intravenous (IV) line to the patient. Harmful contaminants such as potassium, fat, and free hemoglobin are removed from the salvaged blood. This blood is returned through a 40 micron blood filter to collect particulate matter and microthrombi. An autotransfusion in the Emergency Department is generally limited to an acute traumatic hemothorax associated with clinically significant hypovolemia.
An autotransfusion should be considered with the anticipated ...