Table 1 Summary of potential protocol components presented to working group members

Communication

1. Call for assistance (from second surgeon, nursing staff, other healthcare providers)

2. Clearly communicate to all members of the operating room team that ICA injury has occurred

3. Seek advice from experienced skull base surgeon (if operator is inexperienced)

Surgical management

1. Recognize massive bleeding event

2. Expose the injury to determine true source of bleed

3. Use four hand technique where possible (with second surgeon)

4. Use two large bore suction catheters (10 French or greater) to expose the injury while deflecting blood away from the camera

5. Use crushed muscle patch (from anterolateral thigh or sternocleidomastoid) for packing

6. Apply firm pressure for 10–12 min

7. Request circulating nursing staff to bring all packing supplies into the operating theatre

8. Consider direct endoscopic vessel closure if adequate intraoperative exposure

9. Utilize hemostatic agents such as Gelfoam© (Pfizer, New York City), fibrin glue, oxidized cellulose packing, thrombin-gelatin matrix, and oxygel

10. Utilize packing materials such as petroleum jelly-based gauze and foley catheter

Nursing considerations

1. Preoperative clarification of blood transfusion consent

2. Have an understanding of where packing supplies are kept (preoperative)

3. Have an understanding of where anesthetic supplies are kept (preoperative)

4. Potential need for extra nursing support once injury has occurred

5. Be prepared to aid anesthetist in resuscitation efforts

6. Insert foley catheter

Anesthetic considerations

1. Preoperative anesthesia evaluation for high risk patients

2. Perioperative preparedness of tests necessary prior to transfusion (i.e. group and screen)

3. Call for help from second anesthetist to aid in resuscitation intraoperatively

4. Obtain large bore intravenous access for resuscitation purposes

5. Depending on circumstances, be prepared to initiate massive transfusion protocol

6. Obtain arterial line to have real-time blood pressure measurements

7. Administer tranexamic acid intravenously

8. Understanding that the main goal is to maintain cerebral perfusion

Neuro-interventional radiology

1. Determination of local centers with capacity for endovascular interventions

2. Alert neuro-interventional radiologist on call and describe need for urgent intervention

3. Consideration of balloon occlusion test if patient is stable

4. Consideration of a stent graft to seal the injury site and maintain cerebral blood flow

Considerations for transfer

1. Alert local transfer service (ambulance, helicopter, or other means)

2. Prepare patient for transfer (leave intubated and secure lines)

3. Primary surgeon should be available in case of secondary or residual bleed during transfer

4. Take epistaxis tray and packing supplies during transfer

5. Notify family members/ next of kin