Trauma resuscitation rooms vary tremendously. They can range from very spacious…
to very tight…
Most trauma bays that I have visited were somewhere between 225 and 300 square feet (21-28 sq meters), although some were quite large (Rashid Hospital in Dubai at nearly 50 sq meters!).
Interestingly, I did manage to find a set of published guidelines on this topic. The Facility Guidelines Institute (FGI) develops detailed recommendations for the design of a variety of healthcare facilities. Here are their guidelines for adult trauma bays:
Single patient room: The clear floor area should be 250 sq ft (23 sq m), with a minimum clearance of 5 feet on all sides of the patient stretcher.
Multiple patient room: The clear floor area should be 200 sq ft (18.5 sq m) with curtains separating patient areas. Minimum clearance of 5 feet on all sides of the patient stretcher should be maintained.
The FGI “clear floor area” corresponds to my “Trauma Bay Working Area”, which is the area that excludes all the carts, cabinets, and countertops scattered about the usual trauma room. California’s guideline of 280 sq feet seems pretty reasonable as the “Trauma Bay Total Area”, if you can keep your wasted space down to about 30 sq feet.
Bottom line: Once again, don’t try to figure out everything from scratch. Somebody has probably already done it (designed a trauma bay, developed a practice guideline, etc). But remember, a generic guideline or even one developed for a specific institution may not completely fit your situation. In this case, the FGI guidelines say nothing about the trauma team size, which is a critical factor in space planning. Use the work of others as a springboard to jump start your own efforts at solving the problem.
This is an uncommon injury. But when encountered it can cause the trauma professional (and the patient) some major headaches. The majority of the vertebral artery injuries you are likely to encounter are caused by blunt trauma. They are generally diagnosed using CT angiography, and the treatment usually consists of low dose anti-platelet agents like aspirin. Occasionally, coiling or stenting using interventional radiology is needed.
But penetrating trauma is a totally different animal. Gunshot is the most common mechanism, because of the small windows available to access the artery within the vertebral canal using a knife. See the course of the artery in the picture below:
Unfortunately, this bony cage also makes it difficult to surgically approach the artery, especially if the field is continually filling with blood.
The techniques for dealing with this injury according to the doctor books are:
Send the patient to interventional radiology. Cutting off flow using coils is the preferred technique. Gelfoam and other products are not used because of the concern for distal embolization (to the brain). Stenting may be a consideration for blunt trauma, but not for penetrating.
Or, obtain proximal control by ligating the vertebral artery as it takes off from the subclavian. Hmm, this requires either a separate incision, or a supraclavicular extension of your neck incision. It takes time and is not as easy as it sounds.
Generally, the trauma surgeon stumbles upon this injury while doing a trauma neck exploration. Bleeding can be pesky, and may serve to obscure the field. My preferred method of control is:
Jam a wad of bone wax into the vertebral canal right where the bleeding is coming from.
Then jam another wad into the canal in the space below it. Proximal control!
Jam one final wad into the space above, if accessible. Distal control!
End of problem. Then do a thorough evaluation for all other injuries and address them. Feel free to share any additional tips that you may have!
I love to hate dogma. And there’s probably nothing in surgery more sacred and more ingrained than how to take care of a wound. Everybody knows that you have to keep surgical or traumatic wounds dry, and that once you can get them wet, showers are good at baths are bad. Right?
And for something as common as wound management, there must be some kind of research, right? Not so! I did quite a bit of digging through the literature since 1966 and managed to find only five papers. Here are the highlights:
A prospective study of 100 patients were randomized to shower or bathe postoperatively. Of note, the wounds were sprayed with a clear plastic dressing before getting in the water. The was no difference in infection rates.
Another prospective study of 100 patients with stapled incisions after spine surgery were allowed to bathe after 2 to 5 days. Compared to historical controls, there were no differences in infection rates even though the study patients had more complex operations than controls.
A prospective randomized study of 121 patients after hernia surgery found no difference in infection between shower and dry groups
A large randomized study of 817 patients similarly showed no difference between shower and dry groups
Another randomized trial of 170 patients showed no difference in infections between shower after 24 hours and control groups
Get the picture? And interestingly, the few wound infections documented in any of the studies tended to occur in the dry groups, although this was not statistically significant.
Bottom line: In general, it is not harmful to get a wound wet after 24 hours. We don’t know exactly why because of the paucity of the literature, but think about it. The water that we shower or bathe in is the same water that we drink. It’s very close to sterile. When we do shower or bathe, the bacteria that come in contact with the wound are our normal skin flora, which are already in and on the wound. Plus, most incisions that have been closed are water-tight within about 24 hours. It’s more likely that using soap and water is good for you because it washes away tons of bacteria, including the pathogens!
Prospective randomised trial of the early postoperative bathing. BMJ 19 in June 1976: 1506-1507, 1976.
Wound care after posterior spinal surgery. Does early grading affect the rate of wound complications? Spine (Phila PA 1976) 21(18):2160-2162, 1996.
Does a shower with postoperative wound healing at risk? Chirurg 68(7): 715-717, 1997.
Modification of postoperative wound healing by showering. Chirurg 71(2):234-236, 2000.
Postoperative wound healing in wound-water contact. Zentralbl Chir 125(2):157-160, 2000.
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