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.
• Excessive blood pressure causes bleeding:
  • Target MAP 50–60.
  • Consider MAP 60–70 in elderly or isolated head injury.
• Use volume to maintain blood pressure.
• Correct coagulopathy early.
• DO NOT GIVE CRYSTALLOID PRIOR TO DEFENITIVE HAEMORRHAGE CONTROL.
• DO NOT GIVE VASOPRESSORS PRIOR TO DEFINITIVE HAEMORRHAGE CONTROL.
• Manage hyperkalaemia and hypocalcaemia.
• Maintain normothermia.
• Minimise patient movement to prevent clot disruption.
• Communicate physiology regularly with surgeons and team.

Equipment

• Airway Trolley.
• Rapid Infuser:
  • May require a dedicated practitioner.
• Cell salvage.
• Large volume central and peripheral access.
• Underbody warmer.
• Warm theatre (ambient temperature 25 degrees celsius).

Drugs to draw up

Monitoring

• Standard AAGBI monitoring.
• Invasive blood pressure monitoring only if it does not delay time to haemorrhage control.

Blood Management

• Declare code red/major haemorrhage as per hospital protocol.
• Ensure blood is available and checked prior to induction.

Induction and maintenance of anesthesia 

• Pre-oxygenate:
  • Consider OPA + 2 x NPA to optimise.
• Manual in-line cervical spine.
• 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 300–500µgfentanyl slowly over first half an hour.

Blood pressure and coagulopathy management

Blood pressure

• Cycle BP at one minute intervals.
• Target: MAP 50–60 mmHg (60–70 in elderly/isolated head injury).
• Use volume and calcium chloride (centrally) to maintain MAP.

Coagulation

• Target an empiric red blood cell:plasma:platelet ratio of 1:1:1.
• Tranexamic acid 1g (may have been given by pre-hospital team).

Maintain ionised calcium > 1.0mmol/l.

Post definitive Haemhorrage control