Dr Anne Weaver London s Air Ambulance CODE RED THE BLEEDING PATIENT

Dr Anne Weaver London s Air Ambulance CODE RED THE BLEEDING PATIENT

Objectives Describe the background to Code Red Describe our Standard Operating Procedure Share our data

The bleeding problem Major haemorrhage is still a leading cause of death in trauma patients The average time for a trauma patient in London to reach a hospital is 66 minutes Few pre-hospital services in the UK routinely carry blood

The problem in London HEMS traumatic cardiac arrest 12 per month die at scene 909 traumatic cardiac arrests only one hypovolaemic patient survived (Lockey et al. Ann Emerg Med 2006) Resuscitation with 0.9% saline 200 pts / yr to Royal London serious blood loss Delay to obtain plasma in hospital

London HEMS patients 24% patients were coagulopathic on arrival in ED No difference in volume of fluid given on scene ie not dilutional effect In ED already behind the game!

Mortality rate normal coagulation: 11% coagulopathic: 46%

Catastrophic haemorrhage in PHC C ABC Tourniquets Novel haemostatic agents Handling and packaging Splintage Permissive hypotension Damage control resuscitation

Code Red pre-alert to MTC Call-sign, Age, sex, mechanism of injury, CODE RED, specific requests eg by-pass, cardio-thoracic surgeon

Pelvic injury

Time to definitive care..

SENIOR MEMBER OF TRAUMA TEAM MUST DECLARE CODE RED if: Systolic BP < 90 Poor response to initial fluid resuscitation Suspected active haemorrhage Activation based on PHYSIOLOGY NOT LABORATORY

CODE RED PROTOCOL Pre-alert from HEMS team More than a massive transfusion protocol

London & SE England Air Ambulances Physician paramedic model Senior clinicians Dispatch protocol targets seriously injured patients Ability to pre-alert any London MTC for a CODE RED

CODE RED what happens? HEMS pre-alert to ED Unique ID generated Blood bank informed of CODE RED hot line 2 units PRBC to helipad Belmont / level 1 - primed with blood Porter sent to lab for FFP (Pack A)

Prehospital CODE RED activation do we get it right? 30 months data 176 CODE RED pre-alerts to MTCs 129 patients to Royal London MOI (129 pts) RTC 58 (45%) Penetrating injury 39 (30%) Fall from height 18 (14%) Other 14 (11%)

Prehospital CODE RED activation Full data set for 126 pts 84 (67%) survived 20 (16%) died in ED or OR 22 (17%) died on ICU 5 cardiac arrest on arrival in ED all died

Prehospital CODE RED Injury Severity Score (126 pts) ISS Mean Median Overall (126) 29.0 27.0 Survivors (84) 22.0 25.0 Died (42) 30.0 28.0 Full data available for 126 patients 42 died (33%)

Prehospital CODE RED Blood products given in first 24hrs Blood products Mean 95% CI PRBC 10.4 8.4-12.3 FFP 4 2.7-5.2 9 patients did not receive any blood products

March 2012 Blood on Board

Golden Hour box 4 units O negative PRBC Data logger Paperwork

Belmont buddy lite Light weight Battery powered Temp sensor Extracts air from circuit Warms blood or saline Pressure limited 300mmHg

SOP - Indications CODE RED in extremis or Traumatic arrest where hypovolaemia is considered to be a contributing factor

SOP - logistics Blood on aircraft and car Reserve box helipad Boxes packed by hospital transfusion team Restock / recirculated every 24 hrs

>1000 missions 50 prehospital transfusions 28 Code Red in extremis 22 traumatic cardiac arrests 11 PLE on scene 10 ROSC 1 infant in arrest to ED

39 PH Txn to ED 24 survived 8 died in ED 3 died in OR 4 died on ICU

Mean age 35yrs 80% male 45% ROSC from TCA

2.4 units PRBC transfused On-scene time 36 mins Hb 14.0 ph 7.07 BE 12.8

10.5u PRBC in 24hrs 8.3u FFP in 24 hrs 141 units PRBC transfused onscene 100% traceability 1 unit PRBC wasted

18 months data 2841 missions 140 pre-hospital transfusions 77 Code Red in extremis 63 traumatic cardiac arrest (45 thoracotomies) 31 PLE on scene 32 ROSC

26 months data 223 patients 535 units PRBC transfused onscene 100% traceability 1 unit PRBC wasted

National impact of blood on board Kent, Surrey and Sussex Air Ambulance Thames Valley AA Coming soon Great North AA (Cumbria and Teeside) East Anglia AA Essex and Herts AA West Midlands CARE team

Ultimate Code Red case 32M Jumped from 6 th floor of car park A patent B tachypnoeic, chest clear C cool, weak radial, HR 130, BP 70, abdo soft, pelvis asymmetrical. D E4 V3 M5, moving left arm, PERL

On-scene management MILS, Oxygen, IV access Procedural sedation Packaging with pelvic splint RSI and bilateral thoracostomies REBOA via right femoral artery 4 u PRBC on scene, 2 u PRBC on helipad TXA and calcium chloride REBOA / Code Red alert

Injuries Vertical shear pelvic fracture Open right humeral fracture Open right ankle fracture Bilateral calcaneal fractures Suspected lumbar spinal compression fractures Suspected tibial plateau fractures

REBOA Resuscitative Endovascular Balloon Occlusion of the Aorta Control of non-compressible bleeding in pelvis / lower limbs Old procedure, new launch in Emergency dept First patient to receive this intervention outside hospital Package of care

The bleeding patient is dying Physician paramedic teams Recognition of serious haemorrhage Utility of pre-alert protocols Massive haemorrhage protocols Pre-hospital transfusion Emergency reversal of warfarin Novel anti-coagulants Aggressive vascular control in the field