TTL tips 4: Code Red

Early haemorrhage control saves lives. Delays increase mortality. Patients with active traumatic bleeding who may require immediate surgery should trigger a Code Red Adult Major Trauma Call (typically via 2222). Early activation mobilises senior clinicians and system resources essential for definitive haemorrhage control. The patients who will benefit the most are those that are still bleeding and who need early/immediate surgical control.

Purpose of Code Red

Code Red exists to reduce time to definitive care. Mortality from traumatic haemorrhage is strongly associated with delays to operative control rather than injury severity alone. Early senior involvement and parallel processing improve system efficiency and patient outcomes. Code Red should be activated based on risk, not diagnostic certainty.

Indications for Activation

Consider activating a Code Red early. If any of the following are present you should activate unless a good reason not to.

• Massive Haemorrhage Protocol activation
• Blood already being given by prehospital team prior to arrival
• Hypovolaemic shock, typically:
  • Systolic BP < 90 mmHg
  • Heart rate > 120 bpm
  • Poor or transient response to resuscitation
• Traumatic cardiac arrest

Physiological criteria are reliable predictors of patients requiring urgent haemorrhage control. Remember that in children, the elderly and in those who take certain meds you may have to adapt this.

What Code Red Delivers

A Code Red call activates:

• Senior decision-makers, and more importantly gets them in the room to make decisions (not on the end of a phone in another place).
• Theatre coordination, facilitating early access to emergency surgery
• Early/immediate blood product availability
• System-wide alignment, enabling parallel resuscitation, transfusion, and operative preparation

Parallel processing is associated with reduced time to intervention and improved survival in major haemorrhage.

Practical Points

Specify required specialties

Do not assume automatic attendance. Request specific surgical specialties early. Senior involvement reduces delays to operative intervention.

Activate early

Over-triage is preferable to under-triage. Under-calling trauma teams is associated with worse outcomes than early over-activation.

Maintain clinical leadership

Code Red facilitates capacity; it does not replace decision-making. Prioritise haemorrhage control over diagnostic completeness in unstable patients.

Key Messages

• Active bleeding with potential need for immediate surgery warrants Code Red
• Physiology should drive activation
• Early senior involvement improves outcomes
• It is acceptable to stand teams down; it is not acceptable to call late

Download one page version at the bottom of this blog.

Further reading

1. Clarke JR, Trooskin SZ, Doshi PJ, Greenwald L, Mode CJ. Time to laparotomy for intra-abdominal bleeding from trauma does affect survival. J Trauma. 2002;52(3):420–5.
2. Harvin JA, Maxim T, Inaba K, et al. Mortality after emergent trauma laparotomy: the role of time to surgery. J Trauma Acute Care Surg. 2017;83(3):464–71.
3. American College of Surgeons Committee on Trauma. ATLS® Student Course Manual. 10th ed. Chicago: ACS; 2018.
4. Holcomb JB, Jenkins D, Rhee P, et al. Damage control resuscitation. J Trauma. 2007;62(2):307–10.
5. Peden CJ, Stephens T, Martin G. Effectiveness of a major haemorrhage protocol. Anaesthesia. 2016;71(1):66–75.
6. Khan S, Davenport R, Raza I, et al. Damage control resuscitation using blood component therapy in trauma. Br J Surg. 2015;102(2):174–82.
7. Tiel Groenestege-Kreb D, van Maarseveen O, Leenen L. Trauma team activation: who benefits? Injury. 2014;45(2):281–5.
8. Rotondo MF, Schwab CW, McGonigal MD, et al. Damage control: an approach for improved survival. J Trauma. 1993;35(3):375–82.
9. NICE. Major trauma: assessment and initial management (NG39). 2016.
10. Figueiredo S, Taconet C, Harrois A, Hamada S, et al. How useful are hemoglobin concentration and its variations to predict significant hemorrhage in the early phase of trauma? A multicentric cohort study. Ann. Intensive Care. 2018; 8(76).
11. Stanworth SJ, Dowling K, Curry N, et al. Haematological management of major haemorrhage: a British Society for Haematology Guideline. Br J Haematol. 2022; 198: 654-667.
12. Isabella Vielba. 2024. Managing Major Haemorrhage in the Emergency Department. https://www.rcemlearning.co.uk/foamed/managing-major-haemorrhage-in-the-emergency-department/