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22 Interprofessional Team Roles
173
can have a profound impact on the overall patient condition,
including hemodynamic stability and respiratory status.
Understanding the measurement and analysis of pulmonary
mechanics is key to effective ventilation strategies. These
measurements often performed by the RRT include plateau
pressures, total and optimal positive end-expiratory pressure
(peep) studies, driving pressure (dened as plateau pressure
minus total PEEP), and lung recruitment maneuvers. In consultation with the physician, they monitor the status of ventilation alerting team members to the level of sedation and
other observations required. RRT’s autonomy includes the
implementation of RRT-driven protocols in the trauma setting such as lung protective strategies (i.e., ensuring safe plateau pressures), ventilation for traumatic brain injury, chest
trauma, and other trauma epidemiology to optimize outcomes. The RRT cross- monitors and shares roles and responsibilities related to preparation, insertion, and monitoring of
arterial lines. They assist with cardiopulmonary resuscitation, chest tube setup and monitoring, and patient transport
and provide mutual support to other team members to ensure
a high-performing team. How these tasks are shared can
depend on available personnel, the workload, the situation,
and the local practice model. The RRT is required to relay
urgency and gain the attention of other team members to
ensure timely action for the most critical patients. This skill
is especially helpful in the complex trauma care
environment.
The nursing roles on the TT are often identied by the
associated taskwork. Roles include a documenter, a procedure/circulating nurse, and a medications nurse. In line with
the ATLS recommendations, nursing membership on a TT
ranges from 2 to 4 nurses depending on the practice model,
department workload, and available personnel [2]. This
number is not inuenced by the NP role, as that role often
acts as a physician assist supporting all aspects of trauma
management. The documenter usually assumes a position at
the foot of the bed close to the TTL, to keep a 40,000-foot
view of the care process. Responsibilities in this role include
documentation of history, assessments, all interventions, and
timekeeping. As a timekeeper, the documenter alerts team
members to time lapses associated with interventions and
medication. Some TTLs prefer to write down necessary
interventions and empower the documenter to assign taskwork to the relevant team member based on priority. This
strategy can decrease the leader’s cognitive load. This primarily relates to frequent interruptions that are a reality as
team members seek input about patient status to inform taskwork. Lastly, the documenter participates in all handovers.
Handovers will always be vulnerable points in the care process for communication errors [16]. With seriously injured
patients, the management is complex, there can be tremendous distractions as patients are moved along the care pathway, and the list of ndings and interventions can be long
[16]. Loss of information can negatively inuence ongoing
management [17]. In a study by Zakrison and colleagues
[13], chart audits exposed missed injuries in 24% of trauma
patients admitted to ICU and clinical information was inconsistent between the Emergency and ICU department in 48%
of patients. Management was changed for almost 33% of
patients when information was reconciled. The authors note
that standardizing handover in trauma patients remains a
shortcoming that must be addressed to reduce communication errors that impact clinical outcomes.
The medication nurse works from the side of the bed closest to the medication cart. Administration of rapid sequence
intubation medications, vasopressors to hemodynamic support, volume expanders, antibiotics, tetanus, administration
of anticoagulation reversal protocols (ACRP), tranexamic
acid (TXA), and sometimes resuscitation drugs are common
in trauma. Vulnerabilities in this role are associated with the
necessary actions the nurse takes to focus and ensure the
medication dose, route, and timing are accurate. Research
suggests this role can experience a high cognitive load which
can create vulnerability to error [18]. For this reason, some
trauma teams assign two nurses to this role or have this role
supported by the documenter. This role is vulnerable to the
loss of situation awareness. Preparation of the medication
requires focus. The nurse often does this with their back to
the patient. Unfortunately, this can lead to the loss of situation awareness as the patient’s condition may have changed
in the time lapse of preparing a medication. To ensure the
medication is still needed, the nurse should verbalize intention to administer the drug and wait for afrmation before
giving it. Fortunately, today many of the medications are
standardized for adults and can be prepared in advance; this
can often be done upon receiving the pre-arrival notication
call from emergency services. A recent simulation study
showed that having medication and oral tracheal intubation
equipment prepared and organized prior to the task, compared to on scene, resulted in improved time to intubation, a
decrease in associated errors, and decreased cognitive load
especially for the person assisting with the intubation [18].
The third nursing role is a procedure nurse. This nurse
usually works on the opposite side of the bed to the medication nurse to reduce congestion around the patient.
Responsibilities in this role include attaching the patient to
the cardiac monitor, vital signs inclusive of temperature, vascular access, trauma labs inclusive of glucose, initiation of
two large bore intravenous catheters and infusion of crystalloid blood products, and, when required, initiation and
administration of the massive transfusion protocol (MTP).
When uid resuscitation requires the use of the rapid pressure infuser, a fourth nurse is often utilized. Other responsibilities include the insertion of an oral gastric tube post
intubation, a urinary catheter to monitor output, wound care,
and splinting. In centers where there is no respiratory
174
E. Sigalet and M. Dubé
therapist, responsibilities would extend to supporting endotracheal intubation.
In different parts of North America, the role of nursing on
the TT continues to evolve. At the University of California,
San Diego, trauma NPs typically work in Emergency or ICU
departments and are educated to work independently and collaboratively with other team members. This is similar in
Canada, with the exception that they are either Adult or
Pediatric NPs. The scope of practice for the NP includes
ordering medical tests, initiating emergency care, evaluating
treatment, caring for wounds, monitoring trauma patient
progress, completing discharges, and communicating with
the families of trauma patients. Additionally, they can insert
or remove chest tubes, take out foreign objects, manage ventilators, address complex injuries, and act as rst assist to
other physicians on the team [3, 19]. The level of engagement
in scope is dependent on the institution’s trauma management
practice model. In North Carolina, trauma centers are using a
new role, identied as a trauma nursing lead (TNL) [20]. In
this State, the TT has two TNLs instead of the more familiar
2–4 nurse model. This designation of nurses has completed
specialty training (certication in some of the courses detailed
above), have extensive experience in trauma nursing, and
some hold paramedic licenses. Nursing taskwork is shared
between the two TNL roles: assistance with primary or secondary surveys, vital signs, vascular access, uid resuscitation including the massive transfusion protocol (MTP),
administration of ACRP, TXA, medications, wound care,
splinting, documentation, and handovers. In this center, the
11 employed TNLs, all pursing advanced education, are an
integral part of the multidisciplinary trauma team. As such,
they participate in trauma rounds, oversee the care for admitted trauma patients, accompany trauma patient to CT scan,
and support all MTP and ACRP infusions in the hospital.
Lastly and as important, they ensure patients receive familycentered care and families become an integral part of the
patient journey [21]. Research at this center suggests many
advantages of using this role. Patients cared for in these centers after this role was started had better outcomes. Time to
the operating theater decreased by 20min. The length of stay
(LOS) decreased by 1 day and up to 2.5days for patients in
ICU.The LOS for patients in hospital who had received MTP
decreased from 36days to just under 22days [21].
Nursing and respiratory therapy play pivotal roles on the
TT.As such they must be afforded opportunities to engage in
simulation to optimize the teamwork skills and task interdependence required in management of a seriously injured
trauma patient. In both professions, team members are
expected to use the teamwork skills to support team communication, coordination, and collaboration in preparing for
an incoming trauma patient, during the care process, and all
handovers. Family-centered care, as with other medical
emergencies, is important to embrace in these care processes.
All team members have a role to play. Trauma patients present with a broad range of pathologies. Communication, coordination, and collaboration will always be the cornerstones
of effective management of both the patient and family.
Key Points
• Trauma team (TT) membership includes nurses,
nurse practitioners, and respiratory therapists in
North America.
• Nursing specialists and respiratory therapists play a
key role in a high-functioning trauma team.
• In North America, the registered respiratory therapist (RRT) is the airway specialist.
• The RRTs are responsible for initiation, maintenance, and discontinuation of mechanical ventilation, administration of oxygen, other aerosol
therapies, and medical gases such as Heliox, inhaled
Nitric Oxide, and Epoprostenol.
• Nursing roles include documentation, procedures,
medication administration, and general support of
all procedures as requested by the team leader.
• It is important to create opportunities for the interprofessional trauma teams to engage in simulationbased practice to hone communication, coordination,
and collaboration among the team members to ensure
the team can provide timely, effective trauma care.
Acknowledgments The author team would like to acknowledge Peter
Dhillon and Tona Laerz who provided their expertise and experience as
Respiratory Therapists.
References
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The Trauma Bay Environment
RondiGelbard andKenjiInaba
23
Introduction
The purpose of the Trauma Resuscitation area is to receive
and triage patients that present to the Trauma Center with
injuries of varying severity. The area is used to initiate resuscitation and facilitate the correct disposition of these patients.
The Trauma Resuscitation area should be designed to accommodate high patient turnover and allow a single team to concurrently manage multiple patients. Its design must take into
consideration such factors as accessibility, imaging needs,
and procedural capability, as well as employee and patient
safety. This chapter will discuss the physical design of the
ideal Trauma Resuscitation area and Trauma bay, and the
necessary equipment for successful trauma resuscitation.
This chapter will also review the importance of direct patient
triage from EMS to OR, as well as the benets of a hybrid
trauma/OR suite for the optimal care of the critically injured
patient.
General Design ofaTrauma
ResuscitationArea
Trauma accounts for over 42 million emergency department
visits and two million hospital admissions annually across
the United States [1]. It is essential that all Trauma centers
have an efcient system in place in order to adequately
receive and manage critically injured patients [2, 3]. In order
to accomplish this, trauma centers should have a designated
Trauma Resuscitation area, often housed within or in close
proximity to the Emergency Department (ED). The design of
the Trauma Resuscitation area should take into consideration
the hospital’s annual and average daily census and should be
of sufcient size to accommodate all admissions and interhospital transfers requiring a higher level of care. In many
centers, especially those with lower trauma volumes, these
rooms are utilized for the resuscitation of all patients, both
trauma and non-trauma, surgical and medical, and this must
also be taken into consideration. The overall number of individual Trauma bays within the Resuscitation area will also
be inuenced by factors such as inpatient bed accessibility
and available stafng, and should be capable of temporary
expansion as part of the hospital’s surge capacity plan in case
of a disaster.
The Los Angeles County + University of Southern
California (LAC+USC) Medical Center is among the busiest Level I trauma centers in the United States. Located
east of downtown Los Angeles, LAC+USC is a 650-bed
hospital that admits over 6000 trauma patients annually. At
LAC+USC, the multi-use Resuscitation area is situated
within the Emergency department and consists of individual rooms each capable of physiologic monitoring and a
wide range of invasive procedures, including thoracotomies and laparotomies. Other functional areas include a
decontamination area, the Triage/Waiting area, and staff
workstations. In addition, a pharmacy, clean and dirty utility rooms, and an adjoining Radiology suite are all considered part of the Resuscitation area. Each of these
components and their spatial arrangement within the
Resuscitation area are discussed separately within this
chapter.
R. Gelbard
Division of Acute Care Surgery, University of Alabama at
Birmingham, Birmingham, AL, USA
e-mail: rgelbard@uabmc.edu
K. Inaba (*)
Division of Trauma Surgery and Surgical Critical Care, University
of Southern California, Los Angeles, CA, USA
e-mail: kinaba@surgery.usc.edu
© Springer Nature Switzerland AG 2025
L. Marshall Gillman, S. Widder (eds.), Trauma Team Dynamics, https://doi.org/10.1007/978-3-031-86312-7_23
Access totheResuscitation Area
The Resuscitation area should be located on the ground
oor for easy access. The layout of the Resuscitation area
should allow easy access for ground EMS crews and direct
access from the helicopter-landing pad for efcient patient
inow. An elevator for direct transportation to and from a
177
178
R. Gelbard and K. Inaba
helicopter pad is critical for patients arriving via rotary
wing transport. For patient outow, there should be access
to the radiology suite, operating room, and the Intensive
Care Unit. The routes should minimize distance and travel
through non- patient care areas where there is public access
protecting patient privacy and promoting public safety. All
elevators in the pathway should be large enough to accommodate the team, patient, and ventilator, and be card-access
controlled to minimize any delay. The access area must be
well lit, and protected parking areas for consultants as well
as EMS and law enforcement should be available.
Appropriate physical barriers should designate “drop off”
zones for ambulances and other transport vehicles. The
entire access area should be secured and large enough to be
used as an external decontamination and triage area in case
of a disaster.
Immediate access to CT scanning improves efciency,
and a system for the electronic display of images (i.e.
Picture Archiving Communications System or PACS)
should be accessible from the Trauma bays and the administrative areas [4]. The CT scanner should be located adjacent to or within the Resuscitation area. A radiology
technician must be notied of the patient’s imminent
arrival and be readily available during the initial evaluation
and management of the patient. Rapid access to the
Room is important for minimizing transfer times of critically ill patients.
Entry to the Pharmacy/medication room should be clearly
marked and secure. The area should be accessible to all clinical areas and have sufcient space to accommodate a pharmacy preparation area. Warmed uids should be housed
centrally. For higher volume centers, a satellite blood refrigerator containing O− or O+ blood and thawed group AB or
low titer group A plasma should be considered. This refrigerator should be located in close proximity to the
Resuscitation area. In an emergent situation, when the
patient’s blood type is not known or compatibility testing has
not been completed, these emergency release products can
be used.
There should be a room for the storage of equipment
and disposable medical supplies that are not currently
being used. There should also be a clean utility room of
sufcient size for the storage of clean and sterile supplies,
and this should have adequate workspace for the preparation of procedure trays and equipment. Access to a dirty
utility or disposal room should be available from all clinical areas. The physical design of the Resuscitation area
should allow for rapid access to additional equipment if
needed. There must be an emergency power supply for the
entire Resuscitation area, and a backup system for lighting should be immediately available in the event of a total
power failure.
Patient Flow andDisposition
All patient ow upon entry should be directed toward the
Reception/Triage area from which the ambulance entrance
should be clearly visible [5]. From here, critically ill patients
can then be directed to the Resuscitation area. At LAC+USC
once the initial assessment and all necessary imaging is completed, the patient is transported via elevator to one of several
different locations depending on their injury: the patient
ward, ICU, Observation Unit, or the Operating Room. The
initial resuscitation should be performed as rapidly as possible. Once the primary survey has been completed and all
immediately life-threatening injuries have been addressed,
patients requiring surgery should be transferred immediately
to the Operating Room or to denitive care without further
delay.
It is important to have a designated transport protocol in
place for moving the patient rapidly and safely to these areas
[2]. The protocol must ensure that the benets of the transport outweigh the potential risks, and that the same standards
of care employed in the trauma bay are also in place during
transport. Prior to intra-hospital transport, all life-threatening
injuries must be addressed and the patient must be deemed
stable enough to withstand transport. A checklist for ensuring that all safety and monitoring issues have been addressed
should be considered. There must be an adequate oxygen
supply for the duration of the transport as well as a selfinating bag with PEEP valve, facemask, and oral airway. It
is essential that the patient be connected to a portable monitor at all times, with pulse oximetry, blood pressure, and
electrocardiography capabilities. Transport equipment
should also include basic intubation equipment, resuscitation
medications, and IV uids. A fully equipped Trauma team,
including a physician, trauma nurse, and respiratory therapist, must accompany the patient to their next destination and
be prepared to administer further resuscitation or transport
the patient back to the Trauma bay or to the OR immediately
if necessary.
Surge Capacity
The physical plan of the Trauma Resuscitation area should
allow for temporary expansion in the setting of mass casualty
events [2]. In the setting of a major disaster, other patient
assessment areas within the Emergency Department should
have the capacity to be converted into functional Trauma
bays and the potential to serve as post-anesthesia care units
if necessary. In the event that patient assessment areas within
the ED cannot be used, waiting rooms, parking areas, and
other access areas can be set up outside to receive and triage
these patients. A hospital-wide disaster plan should be in
place to streamline this process in the event of an emergency
23 The Trauma Bay Environment
179
[6]. This requires communication and cooperation among
other services within the hospital. Medical and surgical
teams must be prepared to decompress the ED and create
space for casualties as quickly as possible.
Decontamination
Although covered in greater detail in Sect. 6, a decontamination area is an essential component of the Trauma
Resuscitation environment. In the event of chemical/biological disasters or radiation incidents, a plan should be in place
for wet and dry decontamination to occur outside of the main
Resuscitation area. An internal decontamination room that is
directly accessible from the Ambulance bay without entering
other parts of the Resuscitation area must also be available.
This room must be equipped with running water, a oor
drain, and a trap for contaminated water, as well as adequate
storage space for personal protective equipment.
Communication
Maintaining clear lines of communication in the Trauma
Resuscitation area is essential for maximizing efciency and
minimizing stress in this busy environment. Telephones
should be available within each Trauma bay and at each clerical area in order to facilitate this. Direct radio communication should be available to the local EMS services, and an
intercom or public address system that can reach all areas of
the Resuscitation area (including Reception/Triage and the
Radiology suite) [6]. Not only is communication between
members of the Trauma team essential, but key personnel
including CT scan technicians, Radiologists, and the OR
teams, for example, must be notied of the patient’s arrival.
All key personnel involved in the care of the critically injured
patient should be kept apprised of changes in the patient’s
condition as well as other important events as they occur. In
designing the optimal resuscitation area, clear sight lines
between Trauma Bays can be extremely benecial when
overseeing the concurrent resuscitation of multiple patients.
Communications systems that involve mobile phones,
radios, and pagers are likely to be overwhelmed during a
mass casualty or active shooter incident. Therefore, a backup
system for ensuring internal and external communication is
essential. This may include overhead speaker alert, mass text
message, or hospital-wide email alert to disseminate critical
information. In the event that all communication systems fail
or are overwhelmed, alternative options include a courier
service or “runners” to deliver important information. A
third-party, off-site source of information, such as the Red
Cross, should also be included in the mass casualty preparedness plan to prevent overloading the hospital’s telephone sys-
tem. In the setting of an active shooter incident, dedicated
lines of communication with law enforcement agencies are a
critical part of the planning process. All emergency departments should work closely with the closest law enforcement
agencies prior to an incident to ensure the responding units
know the response plan as well as the location of and access
points to the critical patient care areas.
Control Center
A central Medical Alert Center (MAC) should be in place for
coordinating the distribution of critically injured patients to
the closest regional Trauma Center. This will be dictated by
the local trauma center availability. In LA County, for example, the MAC serves 13 Trauma Centers with over 20,000
trauma activations annually [7]. Communication begins
when the MAC center receives a call from the emergency
medical service regarding a critically injured patient. The
MAC will then alert the Trauma center that a patient is en
route to the hospital. The Trauma center should then have a
system in place for announcing the arrival of the injured
patient to the Trauma team at any time of day or night, in
order to ensure their timely arrival to the Trauma bay. The
MAC center is also responsible for coordinating the distribution of patients in a mass casualty incident. Coordinated and
timely communication between the MAC and Trauma center
is essential for notifying the Trauma team of patient injuries
and giving all personnel adequate time to prepare.
Security Considerations
Every Trauma center should ensure the safety and security of
the employees, as well as the patients and their visitors. The
entrances to the Trauma Resuscitation area must be monitored at all times and access from waiting areas to the treatment areas should be restricted. Security personnel should be
immediately available to the Resuscitation area in case a
safety or security issue arises, and have the ability to remotely
monitor the remainder of the patient care areas and waiting
room [8]. Access to the Trauma Center should be secure with
an enclosed area that can be used for external triage, mass
decontamination, or for high-prole patient management.
Having a secured entrance area is also critical as hospitals
and healthcare facilities are high-risk targets for active
shooter incidents [9]. In addition, the possession of weapons,
even among trauma victims who come through the
Emergency Department, is not uncommon [10]. Having a
security plan in place to screen all patients entering the
trauma bay, using metal detectors or physical examination,
will allow for weapons to be detected and secured prior to
them entering patient care areas [10].
180
R. Gelbard and K. Inaba
In the event of an active shooter event, it is essential to
have a response plan in place. In non-healthcare settings, the
“run, hide, ght” strategy has been shown to be effective.
However, many of the patients in the emergency department
and trauma bay will not be able to comply with this. Instead,
a “secure, preserve, ght” strategy has been proposed as an
alternative approach in the healthcare setting [9]. Patient care
areas where life-sustaining treatments can be provided during the incident must be identied and secured with locking
devices or barricades. The optimal design of the emergency
department and trauma bay areas will allow for compartmentalization, with access points that can be rapidly sealed,
allowing this life-sustaining patient care to continue.
The Trauma Bay
Resuscitation areas will vary in the number of individual
“Trauma bays” that they contain. These are often separated
by movable partitions in order to maintain patient privacy but
allow communication and direct sight lines in cases of multiple casualty incidents. The physical layout of a typical
civilian trauma bay is shown in Fig.23.1.
Each Trauma bay should have a bed in the center that
allows for complete access to the patient from all directions.
The Trauma bay must have adequate lighting and sufcient
space to allow for movement of staff and equipment around
the work area. A portable ventilator is usually located at the
head of the bed, along with a large monitor that is clearly
visible to all Trauma team members. The monitor should be
capable of displaying hemodynamic parameters including
electrocardiogram (ECG) tracings, non-invasive blood pres-
sure (NIBP), pulse oximetry, respiratory rate, and body temperature [11]. Lab values including thromboelastography
(TEG) tracings can also be projected for the team to see.
Each bed space should be equipped with a wall-mounted
ophthalmoscope and otoscope, and might contain infusion
pumps, uid warming devices, rapid infusion systems, and a
portable monitor/debrillator. At LAC+USC, a boommounted ultrasound machine is located at the head of the bed
in each Trauma bay, allowing for immediate Focused
Assessment with Sonography for Trauma (FAST) and eFAST
during the initial assessment of the patient.
Each Trauma Bay must be equipped for the active resuscitation of at least one patient. If the surge capacity plan involves
housing multiple patients in a single room, redundancy in the
resuscitation equipment must be considered. Equipment and
supplies should be organized on clearly labeled shelves or
mobile carts. Mobile carts allow for convenient one-stop
shopping and minimize wastage of actions and time of the
trauma team. These might include an airway cart, surgical
procedure cart, and an IV access cart [2]. The airway cart
contains equipment such as laryngoscopes with various
blades, masks, bag-valve-mask devices, suction devices, carbon dioxide detectors, stylets, and endotracheal tubes of different sizes. Equipment for difcult airway situations,
including cricothyrotomy, should also be readily available.
The procedure cart must contain sterile gloves, masks,
gowns, and eye protection, as well as equipment for the insertion of central venous catheters, thoracostomy tubes, nasogastric tubes, and bladder catheters. The cart should also
contain pre-labeled sterilized trays with supplies for diagnostic peritoneal lavage, thoracostomy tubes, and resuscitative
thoracotomies. These procedure carts must be checked for
Fig. 23.1 Photograph of the
physical layout of a typical
trauma bay. A bed is shown in
the center of the room. A
monitoring display, IV poles,
and a wall-mounted
ophthalmoscope and otoscope
are located at the head of the
bed. Equipment and supplies
are located on clearly labeled
shelves at the back of the
room. Off to the right, there is
a workstation containing a
computer and forms for
documentation, and to the
left, disposal containers for
used needles and other sharp
objects
23 The Trauma Bay Environment
181
inventory and replenished immediately after use. The IV
access cart contains the necessary supplies for the insertion of
peripheral venous catheters, arterial catheters, central venous
catheters, and intra-osseous catheters, as well as blood sampling tubes and IV uids. Disposal containers for used needles and other sharp objects should be accessible within each
room, and a cart containing suture materials, splinting materials, and immobilization devices such as cervical collars and
pelvic binders should be located nearby. Each Trauma bay
should contain a sink for hand washing as well as dispensers
with non-sterile latex gloves, gowns, masks, face shields, and
shoe covers to assist with personal protection. At LAC+USC,
there is also a pneumatic tube system within the Resuscitation
area for the rapid transport of blood samples to the central
laboratory. The use of pneumatic tubes has been found to signicantly decrease turnaround times for laboratory results
and to improve the overall efciency of patient care [4].
Trauma Observation Unit Setup
A Short Stay or Observation Unit is an effective way of managing patients with an expected length of stay less than 24h.
At LAC+USC, the Surgical Observation Unit (SOU) contains 10 beds and is staffed by nurses in a 2:1 ratio, as well as
mid-level providers. It is easily accessed from the
Resuscitation area and is adjacent to the OR.Patients who
require close serial clinical examinations as part of nonoperative management of a penetrating injury, or who require
resuscitation prior to operation, can be moved here, decompressing the resuscitation areas.
Special Situations
Noise Discipline inTrauma Resuscitation
According to Chhangani etal., the level of ambient noise is
inversely related to the coordinated activity of the trauma
team [2]. A professional environment without excessive
noise should be maintained at all times within the Trauma
Resuscitation area. Keeping ambient noise to a minimum
will minimize patient anxiety, improve team efciency, and
allow the Trauma team leader to be heard by all those participating in the resuscitation. This is particularly important in
Mass Casualty Incidents.
Resuscitation intheOperating Room
The unstable patient with a clear mechanism of injury
requiring operative intervention may bypass the Trauma bay
and proceed directly to the Trauma Operating Room. The
Trauma OR is ideally located near or adjacent to the
Resuscitation area to minimize transportation times, and
should be appropriately staffed by a dedicated team that
includes an Anesthesiologist, circulating nurse, scrub nurse,
and additional OR personnel depending on the nature of the
injury. The Trauma OR should be immediately available
24h per day and be prepared to accommodate an unstable
patient with little advanced notice [12]. In addition to the
equipment found in the Trauma bay, the Trauma OR also
contains an anesthesia machine, multiple infusion pumps,
auto- transfusion devices, and access to sterilized surgical
supplies.
Hybrid Operating Rooms
Over the past several years, hybrid operating rooms have
emerged that combine interventional and surgical procedures for the care of the critically injured patient. The
hybrid OR, equipped with a xed C-arm and angiography
table, allows for specialized interventions to be carried out
simultaneously and therefore maximizes efciency
[13–15]. Unstable patients with signicant hemorrhage
from pelvic fractures, for example, can be transported to
the hybrid OR for pelvic packing and internal iliac artery
control followed by angioembolization without ever leaving the Operating Room. The layout of a typical hybrid
Trauma OR is depicted in Fig.23.2. Hybrid ORs will be
covered furtherin Chap. 25.
182
Fig. 23.2 Photograph of a
typical hybrid operating room
at a Level I trauma center. The
OR contains the same
equipment and materials as
the Trauma bay, all arranged
around a centrally placed
operating room table. The
hybrid OR is also equipped
with a xed C-arm and
angiography table that allows
for specialized interventions
to be carried out
simultaneously
R. Gelbard and K. Inaba
Conclusion
A well-designed Trauma Resuscitation area facilitates the
rapid mobilization of personnel and resources, and streamlines the evaluation, resuscitation, and treatment of critically
injured patients. The physical design of the space not only
impacts staff workow and communication but also directly
affects all steps of the patient triage and resuscitation. In this
era of cost containment, building exibility into the design
will ensure maximal efciency in usage of the space while
allowing for rapid ramp-up in case of mass casualties. As
future technological advances occur, exibility in design will
also allow the resuscitation area to adapt and continue providing optimal care.
Key Points
• The design of the Resuscitation area should allow
for efcient patient inow and outow.
• The entrance to the Resuscitation area should be well
lit with designated “drop off” zones; it must be secure
and large enough to be used as an external decontamination and triage area in case of a disaster.
• The physical plan of the Trauma Resuscitation
areas should allow for temporary expansion as part
of a surge capacity plan.
• An Observation Unit is an effective way of managing patients who require close serial examinations
or resuscitation prior to surgery and can decompress the Resuscitation area.
• Preparation is critical and the Resuscitation area
should include all necessary equipment and supplies for the physiologic monitoring and active
resuscitation of the trauma patient.
• Communication is key, and the design of the
Resuscitation area must ensure clear lines of communication at all stages of patient triage and
resuscitation.
• A strategic response plan and specic security measures should be in place to reduce potential harm in
the event of an active shooter incident.
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