Trauma is a surgical disease, and specifically, a disease of bleeding. So many of the tools and processes we have developed for its management revolves around the control of hemorrhage.

When a major trauma patient arrives in the resuscitation room, the initial management involves rapid assessment and correction of life-threatening conditions. Recognition of bleeding is paramount. A rapid decision must be made as to the source of hemorrhage and the best way to control it.

Traditionally, bleeding control has been relegated to the operating room. Body cavities are opened as appropriate, and exsanguination is controlled by clamping, repairing, and/or suturing.

However, some body regions are much more challenging. The most notable is the pelvis, and specifically, the unstable pelvis. In the old days, after wrapping or applying an external fixator, the best we could do was to ligate the internal iliac arteries bilaterally and hope the bleeding would slow down sufficiently (it never really stopped) so that internal packing might have a chance.

As the use of interventional radiography grew in trauma, it became possible to noninvasively occlude the internal iliacs. And then, the radiologists became skilled enough that they could selectively identify and embolize more distal bleeding vessels that would dramatically shut down pelvic bleeding.

But this introduced a conundrum. OR vs IR? Where to go after the trauma bay? I’ve long said that the only place an unstable trauma patient can go is to the OR. Not CT, and certainly not the radiology department.

Only the OR, because that’s the only place that something can actually be done about the bleeding. However, that’s not entirely true now.

Here’s the traditional algorithm for a patient with hemorrhage from pelvic fractures:

They go to the operating room OR interventional radiology. If they start in the operating room and can be stabilized (think external fixation and/or preperitoneal packing), then they might be able to be packaged and taken to IR for embolization. And likewise, if they were initially stable enough to go to IR but crash there, then they must immediately be taken to OR.

But what if you could do both in one room?! That’s the beauty of the hybrid room! It is entirely possible to do two, three, and maybe more cases on the same patient in the same room. Hence, the hybrid OR.

Next post, is the hybrid OR for trauma useful?

A hybrid operating room is a special suite that allows advanced imaging to be carried out at the same time as one or more additional operative procedures. It’s that simple. It contains specialized imaging equipment including fluoroscopy and infusion equipment for radiographic dye administration. Some also contain CT and/or MRI capabilities, although the shielding required for these makes them very rare. It is generally stocked with a variety of endovascular

devices and supplies. The usual anesthesia circuits are available, as are selected surgical packs, typically related to vascular and CV surgery.

These suites are typically large, and can easily accommodate multiple operating teams. However, they are very expensive in a number of ways.

First, they take up a great deal of space. Many have the square footage of two or more standard operating rooms. Initial construction costs are very high, as are remodeling and maintenance costs. They can also tax the hospital engineering infrastructure, from electrical to plumbing to ventilation.

But if a hybrid room is available, it can deliver significant benefits to the hospital and to patient care. Intraoperative imaging can provide immediate quality assurance, and patients can undergo more complex procedures and enjoy a shorter length of stay.

Next post, why use a hybrid room for trauma?

Over a year ago I published a series on using the hybrid room for trauma cases. In the meantime, some new papers have been published on this concept. Over the next two weeks, I’ll be refreshing and republishing this information to help you optimize the use of yours, or to support your efforts to get one if you don’t.

While quite a bit of trauma care is routine, involving simpler, single system injuries, a small subset of our patients sustains major, multi-system, and life-threatening ones. They require rapid access to skilled trauma professionals and advanced resources including imaging, operating rooms, and other procedures.

In most trauma centers, initial resuscitation takes place in a trauma resuscitation room in or near the ED. Some diagnostic imaging can be performed there, but more sophisticated studies may require a short (or longer) road trip. Operating rooms and other procedural areas are also usually more distant. And most importantly, each of these areas is designed for a single discipline. Diagnostic radiology has equipment, technicians, and radiologists available. Interventional radiology contains the specialized equipment needed for this more invasive procedure. ORs are designed specifically for surgical procedures, and frequently contain equipment for a single surgical discipline.

But some of our patients require it all! Think about a patient who arrives after a major car crash. Blood pressures are soft, the pelvis is grossly unstable, FAST exam is positive, and there is bleeding from the vagina.

How do we prioritize? Where do we go first? How long will it take the interventional radiology team to arrive? Where’s that external fixator equipment? Can we slip in a CT scan? Where’s OB/GYN??

The solution is right under our nose! Many hospitals have added so-called “hybrid ORs” to their operating suites in order to address the needs of their vascular and cardiovascular surgeons. The next several posts will cover everything you need to know about this important tool for trauma care. I’ll review:

• What is a hybrid OR, exactly?
• Why use a hybrid OR for trauma?
• Is the hybrid OR for trauma useful?
• Which patients may benefit from a hybrid OR?
• So you want your own hybrid room?!

Next post: what is a hybrid OR, exactly?