Since CT is a default path for the majority of stable multi-trauma patients and since it is a time-dependent priority in patients with traumatic brain injuries, resuscitative efforts in the primary survey are often directed toward moving the patient efficiently from the trauma bay to CT. The TTL should remain vigilant about and immediately address lulls in the progress of this transfer. If there is any concern about the need for operative intervention after the scan, the OR and relevant surgical services (e.g., neurosurgery) should be informed and on standby so that a time-consuming transfer back the ED can be avoided.

Angiography: The role for angiography in unstable patients is limited to a very few clinical scenarios. Some groups of investigators have advocated for the use of angiography for the control of hemorrhage in patients with solid organ and pelvic injuries whose hemodynamics can be maintained with active resuscitation (transient responders) [9, 10]. However, extreme caution must be exercised when contemplating such a move, and the full spectrum of resuscitative capabilities and personnel should be transferred to the angiography suite along with the patient. Resuscitation can be difficult under these circumstances, with a sterile field and radiography limiting access to the patient and without the usual equipment available for resuscitative procedures. Furthermore, since most hemorrhagic injuries of the liver and pelvis are venous, angiography may be of limited utility in many of these injuries. That said, if no surgically accessible injuries are identified in the primary survey and a patient’s hemodynamic stability can be maintained with a carefully controlled resuscitation, the risks of angiography may be justifiable. In general, angiography usually follows CT, where contrast extravasation in the arterial phase pinpoints specific areas of active arterial hemorrhage, and CT rules out the immediate need for operative intervention [11]. For patients with suspected pelvic fractures and bladder injuries, pelvic angiography should be completed before retrograde urethrograms or cystograms to ensure vascular contrast extravasation in the pelvis can be detected.

Operating room: The operating room is an ideal destination for patients in shock. With dedicated surgeons, anesthesiologists and nurses present, and a full spectrum of resuscitative options and equipment available, resuscitation can be intensified and titrated against continuous hemodynamic monitoring. With better lighting, sterile technique, and equipment, procedures such as chest tube and line placement, exploration of wounds, and completion of resuscitative thoracotomy can be done more safely and more precisely. However, for unstable patients, a partially unmonitored move to an incompletely prepared operating theater can be hazardous. Transfer to the operating theater is a critical transition (Fig. 16.2), whose benefits can be maximized by careful mitigation of risks. Some trauma centers have full operating theater capabilities in the resuscitation area, allowing the resuscitation to blend seamlessly with definitive surgery for damage control. Locating surgical capabilities in the resuscitation area has been associated with better outcomes for some of the most unstable patients [12]. When such capabilities are not available, it may still be possible to create a smooth transition between the trauma bay and the operating room. The OR should be part of the trauma activation callout and OR personnel, including anesthesia and nursing, should begin to arrange operative capacity for a potential imminent transfer. The trauma team leader and the OR should be in close communication throughout the resuscitation, and the decision to transfer to the OR and the anticipated resource and equipment needs should be specified as early as possible (Fig. 16.3). Some operating theaters have prespecified trauma laparotomy trays, complete with vascular and thoracic instruments, along with appropriate retractors, and even sternal saws that can be rapidly opened as needed. It is important that the OR setup for trauma is predefined, but even if it is, it is useful for the TTL to conduct a briefing to ensure that the assembled team is aware of the risks, expected operative strategies, and anticipated equipment needs. Ideally, the trauma patient will arrive from the trauma bay to a fully staffed, warm operating room, with monitoring interfaces and operative instruments set up and ready to go. Even, or perhaps especially, in this operative crisis situation, a preoperative briefing and a time-out, as defined by the WHO Safe Surgery Saves Lives campaign, are essential to set the direction for the case [13].

In some cases, a thorough primary survey, including chest and pelvic X-rays and an extended focused assessment with sonography for trauma (eFAST) ultrasound exam of the chest and abdomen, may not reveal a clear, single cause of hemodynamic instability, and an unstable patient may arrive in the operating room without a clear operative plan. Some operating rooms are equipped with diagnostic modalities and expertise, including transesophageal echocardiography, X-ray, ultrasound, interventional radiology, and an upper and lower gastrointestinal endoscopy to quickly repeat or intensify the workup of undifferentiated trauma patients. When the source of hemorrhage is difficult to identify (when diagnostic imaging is not directive), the abdomen is the usual suspect. Investigators at the University of Southern California (USC) observed that exploratory laparotomy was required much more frequently than exploratory thoracotomy (89 % versus 1.9 %) for unstable patients with thoracoabdominal trauma. They suggested abdominal exploration should be prioritized over thoracic exploration in this instance [14]. The team should, however, be prepared to do both, although this was rarely required in the USC series (2.1 %). Operative interventions in hemodynamically unstable patients should have defined objectives and clear onward disposition options. Hemodynamic instability is often associated with acidosis, coagulopathy, and hypothermia, which justify a damage control surgical approach that prioritizes early control of hemorrhage and contamination and abbreviation of operative efforts [15]. TTLs can decide on this course of action even before a patient’s arrival in the operating room and should know the onward disposition from the operating theater even before a patient arrives there. For example, if a traumatic brain injury was suspected, but a CT of the head could not be obtained in advance of an urgent exploratory laparotomy, arrangements can be made for immediate postoperative transfer to CT. Alternatively, if a patient with a complex pelvic fracture is taken to the operating room for thoracic or abdominal injuries, the interventional radiologists and angiography suite can be readied in advance for possible direct transfer from the operating room to the angiography suite. Finally, if operative intervention has been successful in controlling hemorrhage, aggressive restoration of homeostasis is best accomplished by rapid, seamless transfer to a briefed and prepared intensive care unit (ICU).