Fig. 10.1
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
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 sufficient 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, noninvasive blood pressure (NIBP), pulse oximetry, respiratory rate, and body temperature [9]. 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, fluid warming devices, rapid infusion systems, and a portable monitor/defibrillator. At LAC + USC, a boom-mounted 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 difficult 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 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 intraosseous catheters, as well as blood sampling tubes and IV fluids. 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 significantly decrease turnaround times for laboratory results and to improve the overall efficiency 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 24 h. 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 in Trauma Resuscitation
According to Chhangani et al., 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 efficiency, 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 in the Operating 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 24 h per day and be prepared to accommodate an unstable patient with little advanced notice [10]. In addition to the equipment found in the trauma bay, the trauma OR also contains an anesthesia machine, multiple infusion pumps, autotransfusion devices, and access to sterilized surgical supplies.
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