Experience of implementing a National pre-hospital Code Red bleeding protocol in Scotland

the Scottish Transfusion and Laboratory Support in Trauma Group (TLSTG), Matthew J. Reed*, Alison Glover, Lauren Byrne, Michael Donald, Niall McMahon, Neil Hughes, Nicola K. Littlewood, Justin Garrett, Catherine Innes, Margaret McGarvey, Eleanor Hazra, P. Sam M. Rawlinson

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review


Introduction The Scottish Transfusion and Laboratory Support in Trauma Group (TLSTG) have introduced a unified National pre-hospital Code Red protocol. This paper reports the results of a study aiming to establish whether current pre-hospital Code Red activation criteria for trauma patients successfully predict need for in hospital transfusion or haemorrhagic death, the current admission coagulation profile and Concentrated Red Cell (CRC): Fresh Frozen Plasma (FFP) ratio being used, and whether use of the protocol leads to increased blood component discards? Methods Prospective cohort study. Clinical and transfusion leads for each of Scotland's pre-hospital services and their receiving hospitals agreed to enter data into the study for all trauma patients for whom a pre-hospital Code Red was activated. Outcome data collected included survival 24 h after Code Red activation, survival to hospital discharge, death in the Emergency Department and death in hospital. Results Between June 1 st 2013 and October 31 st 2015 there were 53 pre-hospital Code Red activations. Median Injury Severity Score (ISS) was 24 (IQR 14–37) and mortality 38%. 16 patients received pre-hospital blood. The pre-hospital Code Red protocol was sensitive for predicting transfusion or haemorrhagic death (89%). Sensitivity, specificity, positive and negative predictive values of the pre-hospital SBP <90 mmHg component were 63%, 33%, 86% and 12%. 19% had an admission prothrombin time >14 s and 27% had a fibrinogen <1.5 g/L. CRC: FFP ratios did not drop to below 2:1 until 150 min after arrival in the ED. 16 red cell units, 33 FFP and 6 platelets were discarded. This was not significantly increased compared to historical data. Conclusions A National pre-hospital Code Red protocol is sensitive for predicting transfusion requirement in bleeding trauma patients and does not lead to increased blood component discards. A significant number of patients are coagulopathic and there is a need to improve CRC: FFP ratios and time to transfusion support especially FFP provision. Training clinicians to activate pre-hospital Code Red earlier during the pre-hospital phase may give blood bank more time to thaw and prepare FFP and may improve FFP administration times and ratios so long as components are used upon their availability.

Original languageEnglish
Pages (from-to)41-46
Number of pages6
Issue number1
Publication statusPublished - 1 Jan 2017


  • Haemorrhage
  • Massive transfusion
  • Pre-hospital care
  • Trauma

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