Emergency theatre and surgery

At the MTC the Theatre coordinator is paged following a code red trauma team alert.  They are tasked with identifying an available theatre and team to accommodate an expected patient until stood down by anaesthetist or ODP.

All code red patients will ideally, but not always go this theatre.  This may include Orthopaedic & Cardiothoracic patients.

• Patients should be taken directly to the operating theatre rather than the anaesthetic room.
• Surgery for haemorrhage control should not be delayed for arterial line insertion and other non-therapeutic monitoring/interventions.
• In un-intubated patients surgery should commence immediately after RSI.
• Patients who require haemorrhage control should not wait in the EMERGENCY DEPARTMENT for consultants and other staff to come in.  They should be immediately transported to the nominated theatre immediately.
• Ensure that blood banks are aware of all movements.
• A pre surgery safety pause must be performed once in theatre.

Consultants from all specialties should be available to attend a major trauma patient or give an opinion within 30 minutes of a referral when deemed appropriate.  Examples are given below:

• Anaesthesia – all emergency major trauma cases.
• General Surgery – all emergency laparotomies.
• Orthopaedics – pelvic packing, compromised limb.
• Vascular – compromised limb.
• Cardiothoracics – all emergency cardiothoracic surgery.
• IR – haemodynamically unstable pelvic fractures.
• Neurosurgery – all emergency craniotomies.
• Urology – haemodynamically unstable high grade renal injuries.
• Plastics – open fractures/compromised limb & burns.
• NT – penetrating neck injuries.
• Maxillofacial – torrential maxillofacial haemorrhage.
• Paediatrics – patients <16 years old.

DCR should be employed in all patients with active haemorrhage who have ANY of the following:

• Acidaemia
• Hypothermia
• Coagulopathy

There are five principles of DCR:

• Damage control surgery.
• Corrective coagulopathy.
• Avoid hypothermia.
• Limit volume (using only blood).
• Time limited permissive hypotension.

Key Principles:

• Primary goal is rapid definitive haemorrhage management.
• Inform ODPs and CEPOD theatre team early if patient requires surgical management. 
• Excessive blood pressure causes bleeding:
  • Target MAP 50-60 mmHg or SBP of 80 - 100mgHg
    • Elderly patients/ isolated head injury
      • Target MAP 60-70 mmHg or SBP of 110mmHg
• Use volume and calcium to manage blood pressure
• Correct coagulopathy early
  • Deliver a balanced transfusion with early use of FFP to manage endotheliopathy.
• DO NOT GIVE CRYSTALLOID before definitive haemorrhage control.
• DO NOT GIVE VASOPRESSORS before definitive haemorrhage control.
• Manage hypocalcaemia (ionised Calcium <1.0mmol/l) and hyperkalaemia proactively
  • Note: Calcium chloride can be used if central access is available. 
• Maintain normothermia
• Minimise patient movement to prevent clot disruption.
• Communicate physiological parameters regularly with the surgical team.

Prepare

Equipment

• Airway Trolley
• Blood Transfusion Board and blood delivery team
• Belmont Rapid Infuser
• Cell salvage
• Large Volume Central and Peripheral Access
• Underbody Warmer
• ROTEM
• Warm Theatre (25°C)

Monitoring

• Use standard AAGBI monitoring.
• Do not delay haemorrhage control to establish invasive monitoring

Drugs

Blood Management:

• Declare Code Red
• Highlight an area as a 'blood station' where blood can be received, checked and documentation completed. 
• Use 'Bloods Boards' to facilitate balanced transfusion. 
• Target an empiric PRC:FFP ratio of 1:1
  • Order an initial 'TRAUMA PACK A' 
    • 4 units universal/type specific PRC and 4 units universal FFP
      • Pre-thawed plasma is available and will be delivered to the emergency department. 4 units of FFP will be automatically thawed by BTS when these units are dispatched. 
  • Proactively order a 'Pack B' if high transfusion requirement.
    
    • 6 units PRC, 6 units FFP, 1 pool platelets, 2 units cryocpreiptate. 
• Anticipate transfusion requirements
• Adult, male code red patients may receive RhD O Positive Red Cells. 
• Early ROTEM
  • Use ROTEM to supplement balanced transfusion.
  • See document ‘Management of Trauma Induced Coagulopathy’

• Ensure blood is available and checked prior to induction.
• Do not give cryoprecipitate unless evidence of hypofibrinogenaemia

Tranexamic Acid (TXA)

The following adults should receive 1g TXA*:

• at risk of bleeding
• confirmed bleeding and a HR >110 and/or SBP <90mmHg or
• GCS <13 with evidence of head injury.

Give a further 1g bolus if there is:

• bleeding requiring ongoing resuscitation and/or hemorrhage control. 
• Confirmed intracranial hemorrhage in patients with GCS <13
• Hyperfibrinolysis or viscoelastic studies

The maximum total dose is 2g. Where all criteria are met it may be appropriate to administer a 2g bolus.  

*Do not give first dose of TXA >3hours from injury unless evidence of hyperfibrinolysis. 

Induction & Maintenance of Anaesthesia:

• Ensure surgeons are scrubbed and ready
• Prepare and drape patient
• Pre-oxygenate
  • Consider OPA + 2 x NPA to optimise
  • Certain circumstances may require a more tailored or delayed approach to allow safe induction (e.g. to optimise oxygenation or cardiovascular status)
• Manual In-Line Cervical Spine Care
• Consider Reverse Trendelenburg position
• Anticipate Hypotension on Induction
  • Ensure Rapid Infuser connected, functional and loaded with blood and products.
• Reduce drug doses and volatile concentration
  • (aim 0.3-0.5 MAC until haemodynamically adequate)
• Antibiotics
• Aim to deliver 300-500mg fentanyl slowly over first half an hour following definitive haemorrhage control.

Communication

• Ensure optimal team communication until definitive haemorrhage control.
• Discuss Damage Control Vs Definitive Surgical options with operating team
• Insert a stop point at 15min intervals (when clinically appropriate) using the following structure ‘SCOTCH”:
  • Surgical Progress
    • Damage Control Vs Definitive Surgery
  • Coagulation and Transfusion Management
    • What blood and blood products have been administered?
    • What is in the room?
    • What is on order?
    • ROTEM analysis
• Oxygen Debt/Acidaemia
  • Lactate/Base Excess Trend
• Temperature
• Calcium and Electrolytes
  • Ionised Calcium and replacement given
  • K⁺
• Heading
  • Time since commencement of surgeon
  • Anticipated duration
  • Do we need any further assistance?
  • Post-operative plan
    • Further imagine?
    • Critical Care?

Post Definitive Haemorrhage Control

• Aim to restore normal physiology
• Use base deficit and lactate to guide volume resuscitation
• ROTEM may be used to deliver targeted coagulopathy management
• Consider Noradrenaline, if required, only once circulating volume is restored and definitive haemorrhage control achieved.