| Before patient arrival |
- Room temperature 25°C or higher
- Warm IV line available
- Machine checked
- Airway equipment ready
- Emergency medications drawn
- Blood bank called to order:
- 6 units of type O negative PRBC
- 6 units of type AB FFP
- 6 units (ie, one "6-pack") of platelets (any blood type)
|
| Patient arrival |
- Patient correctly identified (ie, site/side) for emergency surgery
- Blood bank called
- Send blood for immediate type and cross
- Initiate institutional massive transfusion protocol
- Establish IV access
- Monitors (ECG, SpO2, blood pressure)
- Pre-oxygenation
- Instruct surgeon to "prep and drape"
|
| Induction |
- Sedative hypnotic (ie, propofol versus ketamine versus etomidate) + neuromuscular blocking agent
|
| Intubation |
- Once ETCO2 confirmed, surgeon to make incision
- Place orogastric tube
|
| Anesthetic |
- Volatile and/or benzodiazepine (ie, midazolam) + opioid (ie, fentanyl)
- Consider TIVA
- Insert additional IV line and/or arterial catheter
- Administer appropriate antibiotics
|
| Resuscitation |
- Send baseline labs (ie, lactate, CBC, chem-7, coagulation panel, thromboelastogram/ROTEM)
- Follow MAP trend
- Consider hypotensive resuscitation (ie, MAP goal >50/SBP goal >90 mmHg)
- Consider early FFP; use 1:1:1 (PRBC:FFP:platelets) ratio for blood product administration
- Goal urine output: 0.5 to 1.0 mL/kg/hr
- Consider tranexamic acid
- Maximal benefit if given <3 hours from injury
- Initial dose: 1 g over 10 minutes
- Second dose: 1 g over 8 hours
- Consider calcium chloride 1 g IV
- Consider hydrocortisone 100 mg
- Goals for concurrent traumatic brain injury:
- SBP >100 mmHg
- SPO2 >90%
- pCO2 35 to 45 mmHg
|
| Closing/post-op |
- Contact ICU for a bed/sign-out to ICU team
- Initiate lung-protective ventilation (tidal volume = 6 to 8 mL/kg predicted body weight)
|
