Conducting a Trauma Operation

A.

The ideal location for a trauma operating room (OR) is adjacent to the resuscitation area. However, this depends on hospital-specific geography and resources. In general, it is more practical to have the trauma OR within the main OR suite for more flexibility of equipment and personnel. It is better to take the patient and the resuscitation team to an OR than try to bring the OR to the patient. A protocol for elevator standby and priority transport must be in place.

B.

A trauma OR should have a minimum space of 400 to 450 square feet with an optimum space of 600 square feet. The following equipment should be available:

• A large, high-quality OR light with two peripheral satellite lights for patients requiring multiple, simultaneous procedures
• Dedicated imaging equipment (built-in, if possible) to move in and out of the operative field
• An OR table that is capable of radiography and fluoroscopy
• A minimum of four suction connections
• A minimum of eight electrical outlets
• Warm intravenous fluids
• A rapid-infusion device
• A blood salvage device
• A multipurpose anesthesia machine capable of high minute ventilation (up to 30 L/min), 20 cm H₂O of positive end-expiratory pressure (PEEP), and pressure-support inverse-ratio ventilation
• Multichannel pressure monitoring with a remote slave monitor
• Multiple x-ray view boxes (minimum eight) or PACS screens
• Patient heating devices
• Electrocautery with argon beam capability
• Rapid access to prepared hemostatic agents
• General trauma tray that includes aortic compressor, rib spreader, sternal retractor, and a variety of vascular clamps
• Head light, face shields and/or goggles, boots, and impervious gowns for the operating team

C. The critically injured patient must be accompanied by the resuscitation team to the OR.

Adequate assistance should be available to move the patient from the resuscitation litter to the OR table; this movement should be directed by the trauma team. In general, the patient should be removed from the backboard, military anti-shock trousers (MAST), or pelvic binder prior to the start of the operation.

D.

For urgent exploratory laparotomy, the patient should have both arms available for adequate access during the operative procedure. Access to the central veins should be in place for most critically injured patients. A cervical collar can be removed after the patient is anesthetized and replaced with two 5-pound sandbags on each side of the head with large tape across the forehead. This allows exposure of the lower neck and clavicular area for central access or subsequent thoracic incisions.

E.

Pulse oximetry, capnometry, pressure monitoring, and electrocardiographic (ECG) monitoring should be applied. The ECG pads should be strategically placed to

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avoid interference with subsequent operative intervention. Warming devices should be placed over those areas not in the surgical field. The patient should be prepped from midthighs to midneck and laterally to the table (Fig. 16-1). In agonal patients, even a 15-second painting or spray with antiseptic is superior to no prep. Draping should be wide and secured in place with staples or sutures.

Figure 16-1. OR patient preparation. (From Champion HR, Robbs JV, Trunkey DD. Trauma surgery (parts 1 and 2). In: Dudley H, Carter D, Russell RCG, eds. Rob and Smith's Operative Surgery. Boston, Mass: Butterworth; 1989:540, with permission.)

F.

In a hypotensive patient with an obtainable blood pressure, the abdomen should not be opened until blood is available in the room. Thus, it is essential to have adequate intravenous access in place, blood immediately available in the room, and the anesthesia team prepared to deal with possible sudden cardiovascular collapse.

G.

A number of techniques are utilized in the OR for trauma care depending on the body region and stability of the patient. In general, the following are useful guidelines:

• Adequate help, light, and suction should be ensured.
• The incision should be large enough for rapid and thorough exploration. The operation should not be compromised by inadequate exposure.
• Blood salvage capability should be ready before opening a body cavity suspected of massive hemorrhage.
• Hemorrhage in most areas can be controlled by precise packing before attempting definitive repair.
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• In an unstable patient, frequent monitoring of hematocrit, arterial blood gases, ionized calcium, and potassium is necessary. A tableside point-of-service analyzer can be useful.
• OR procedures presented in topic-specific chapters in this manual should be followed.