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Discussion

Sequential Concurrent Surgical Fields - Trauma

Has anybody been in a trauma case where the patient had two significant injuries that required establishing two separate surgical fields (sequentially)?

I was called in at 2AM for an adolescent MVA - she was evaluated in trauma and scans indicated the need for a decompressive craniectomy. She was placed in the 'sitting position'. I was second assist and about 90 min into the craniectomy, her IAP began to spike (~20 mmHg). Could actively see her belly swelling.

Decision was made to cover the craniectomy and had another team immediately scrub-in for a 'crash laparotomy' - I began the prep as others repositioned her to supine. By the time the trauma attending did the midline, her belly was severely distended to the point she looked pregnant. Never seen so much blood pour out of an abdomen (even a ruptured AAA) upon opening and we lost pressure as the team struggled to find the source. They cracked her, but was futile.

Has anybody had this happen? It was probably the most intense case I've scrubbed in a long time just because we ditched one critical field for another. Would appreciate others' perspectives and experiences...

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    Not the scenario you're describing, but we've had some where neuro was doing a crani at the same time trauma was doing a laparotomy. We did keep the fields separate- each had their own count, their own table, their own kick bucket, their own sponge counter set up. And a lot more staff! A lot more controlled than what you're describing as both knew they'd be working at the same time and compromised on things like positioning and turning the table 45 degrees instead of the normal 90 for the crani while in the elevator.

    Maybe a bit more similar but not trauma- we had a thoracotomy patient code in the middle of the surgery. We threw an Ioban drape over the incision and went supine very quickly to start compressions. Made it out of the OR with that one.

    Another maybe similar with blood loss- patient had a known AAA. So when they presented in the ER with major back pain, hemodynamically unstable, they skipped the scans and brought him to the OR. Abdominal surgery never revealed a source of bleeding and anesthesia started having difficulty ventilating. Surgeon decided to place a chest tube. It was like the patient's entire blood volume came shooting out of the tube- we didn't even have time to call the cardiac surgeon who was in the lounge after just finishing their first case of the day. Undiagnosed thoracic aneurysm is what blew, not the AAA.

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    Yes, this type of situation happens from time to time. Usually we know, we may need to run concurrent procedures, but sometimes we don't. That's the nature of some of our most critically injured patients, and we are a trauma center with everything that goes along with it. I've actually seen it play out the opposite way - where a patient is having an ex lap and then has to have a decompressive hemi crani added.

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    Had that happen several times in Afghanistan were we had general surgeons working on the abdomen and orthopods working on the limbs.

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