Sounds like an easy question, right? In the trauma resuscitation room! But how long can (should) they stay there? Can they leave for testing and come back? As you may expect, there are a lot of variables to consider.

All major trauma patients should start in the resuscitation room. In a few institutions around the world this may be an OR, but this is uncommon. I’m talking about major injuries, multiple fractures, significant potential for blood loss, not the minor stuff. Once the necessary stabilization and evaluation is complete, the patient may need further diagnostics like CT or plain xrays. But once those are done, where does the patient with ongoing resuscitation needs go?

In many cases, they end up back in the ED. Some surgical specialists may want to evaluate them there. They may need minor procedures like suturing or traction pin placement. An ICU bed might not be immediately available. But is this really the right place?

Unfortunately, it isn’t. This class of patient needs ICU care, which includes very close monitoring and ongoing attention to resuscitation. This level of care is just not available in a busy emergency ward. The physicians are seeing other patients, and the nurses may be less familiar with continuously providing this level of care. Arterial line and ICP placement / monitoring is difficult. It’s really not the right place to be.

Bottom line: There are only two places for a complex patient with ongoing resuscitation needs: a surgical ICU or an operating room. The choice depends on whether the patient really needs an operation now. If not, they should be resuscitated in an ICU prior to general anesthesia. The trauma physician must triage all requests for tests or minor procedures from consultants, keeping the overall patient condition in mind. If a particular test will not significantly alter near-term management, it must be postponed. If an ICU bed is not available, the ED resuscitation room may be the only alternative. In this case, a nurse (preferably with ICU experience) must stay with the patient at all times. And an experienced trauma physician should ideally be there as well, if not in person, at least by phone (and quickly). Finally, get the patient to an ICU as soon as humanly possible!