1. Code Crimson

2. 2 After completing this module staff will be able to: –Explain the purpose of the Code Crimson –Identify departments affected by Code Crimson –Identify criteria for calling a Code Crimson –Discuss patients at an increased risk for active hemorrhage, requiring massive transfusions –Discuss the various roles and responsibilities of staff involved in Code Crimson Objectives

3. 3 A process for timely and adequate replacement of blood products To reduce the incidence of coagulopathy Attempt to prevent exsanguination Decrease turnaround times of receiving blood Prevention of wasting blood products Purpose of Code Crimson Policy

4. 4 Code crimson applies to any patient requiring a massive transfusion (defined as more than 10 units PRBC’s in a 24 hour period), in which the volume of blood approaches or exceeds the replacement of the recipients total blood volume. Applies to, but is not limited to: medical/surgical emergencies, surgeries, OB hemorrhage (refer to policy 7400.0208 for OB Hemorrhage Nursing Management), etc. Policy

5. 5 Critical Care Emergency Department (ED) Operating Room (OR) Labor and Delivery (L & D) Clinical Laboratory Blood Bank Departments affected

6. 6 Systolic blood pressure 120 beats/min accompanied by signs and symptoms of shock related to hypovolemia Signs and symptoms of hypovolemic shock include: tachypnea, tachycardia, decreased blood pressure, narrowed pulse pressure, pale, decreased urine output, mental status changes, and/or delayed capillary refill. Actively Hemorrhaging These patients can deteriorate rapidly. Vital signs may remain relatively stable until 30-40% of circulating blood volume is lost (1500-2000 mls). (Copstead & Banasik, 2010). Criteria to initiate Code Crimson

7. 7 Blunt or penetrating thoracic and/or abdominal trauma Hemorrhage may be internal such as seen with liver lacerations, spleen injuries, pelvic fractures, aorta injuries, etc. (Emergency Nurses Association, 2007). Antecedent coagulopathy Seen in conditions such as Hemophilia, liver failure with compromised bleed times, idiopathic thrombocytopenia (ITP), coumadin for clot prevention/treatment, etc. With a source of trauma, a vascular surgery, medical cause (ex. Variceal bleeding), or OB hemorrhage massive bleeding can occur. Any patient presenting with need for 10 or more units of blood within a 24 hour period Criteria Continued

8. 8 Any designated person may contact the hospital operator to overhead page “Code Crimson” for additional resources Who responds? –House Supervisor –Phlebotomist –MET team –ED Physician Activation of Code Crimson

9. 9 –Establish 2- large bore IV lines (preferably 18 gauge or larger) –Communicate with Blood Bank –Obtain signature for emergent crossmatch release for uncrossmatched units from physician –Assure blood specimens are collected –Administer blood products as ordered and per policy for Blood and Blood product Administration Policy No, 8720.00035 RN responsibilities

10. 10 –Monitor vital signs –With rapid transfusion, blood products can infuse in less than 15 mins, document at least a pre-transfusion and post-transfusion set of vital signs for each transfusion. –A fluid warmer should be used to prevent hypothermia and coagulopathy (RN must have demonstrated competency on the Level One Rapid Infuser and Hotline Fluid Warmer). –Notify blood bank to thaw 2 units of FFP for transfusion when ready, and transfuse FFP after 5 units of PRBC’s are given. RN responsibilities continued

11. 11 – Intervene and treat patient – Monitor effectiveness of transfusions – Record all intake and output – Anticipate multiple lab draws/orders including but not limited to: CBC, type and cross, DIC panel, ionized Calcium, PT/PTT/INR –Document: vital signs based on patient acuity, all blood and fluids infused, urine output, observed reactions and actions taken on the blood transfusion flow sheet, administration of blood and blood components on blood transfusion flow sheet. RN Responsibilities continued

12. 12 –Determine the timing and need for massive transfusion –Establish a central line if peripheral IV access is unobtainable –Sign emergent crossmatch release for uncrossmatched units –Order 5 units of uncrossmatched O-negative blood for transfusion immediately –Order type and cross for 10 units of PRBC’s and transfuse type specific as soon as available (RN and MD responsibility). Physician Responsibilities

13. 13 –Phlebotomist to respond immediately to Code Crimson location –Anticipate drawing blood for type and cross as well as more blood for analysis –Anticipate processing uncrossmatched blood for delivery to appropriate location for transfusion immediately –Deliver blood products via blood cooler every 30 minutes to location of Code Crimson, unless otherwise indicated by physician –Anticipate multiple lab orders Laboratory responsibilities

14. 14 –Assist primary nurse and department staff to stabilize patient –Facilitate and assist with transportation of blood and blood products for transfusion –Assist with minimizing unnecessary staff present at time of Code Crimson –Facilitate communication with family if necessary MET team and House Supervisor Responsibilities

15. 15 Copstead, L. E. & Banasik, J. L. (2010). Pathophysiology (4 th Ed.). St. Louis, MO: Saunders Elsevier Emergency Nurses Association (2007). TNCC Trauma nursing core course provider manual (6 th Ed.). Des Plaines, IL: Emergency Nurses Association Nunez, T.C & et. Al. (2006) Creation, implementation, and maturation of a massive transfusion protocol for the exsanguinating trauma patient. The Journal of Trauma: Injury, Infection, and Critical Care, 68(6), 1498-1505 References