So, in our latest Code Brown, I wrote on a crashing trauma patient. Scott Weingart made a comment where he also noted that transfer between OR and angio might come to an end with RAPTOR like operating theatres. RAPTOR is a cool name that’s made to fit with Resuscitation with Angiography, Percutaneous Techniques and Operative Repair. In essence, a hybrid OR/angio suite that could transform trauma surgery.

Trauma Goes Hybrid
These RAPTOR suites are pretty much the wet dream of any in-hospital resuscitationist or trauma surgeon. One of the problems with angio suites in many hospitals is that they were built before interventional radiology became a big hit, and before treating unstable, anaesthetised patients were even considered. Most angio suites I’ve seen are pretty hard to access from an anaesthetist’s point of view, and aren’t set up for the logistical demands of a trauma theatre. But these new hybrid suites would hopefully have the great mix of a well thought out OR and a big angio set-up, and have the logistics to back it up. Yup, sounds pretty good.

Chance has it that my current hospital is in the process of building a hybrid OR/angio suite with its new thoracic surgery unit. It’s planned to be used for hybrid operations using open surgery in conjunction with percutaneous techniques, for stenting of small and large vessels, valve repair and for running angio during procedures to see the results immediately. So, mostly for cardiothoracic surgery and aortic surgery – but the neurosurgeons have also expressed interest in using it.

Weingart’s suggestion was the first time I heard about using these hybrid suites for trauma surgery management. I found a very interesting editorial letter as an introduction to RAPTOR and using hybrid suites for trauma. An interesting read:

The RAPTOR: resuscitation with angiography, percutaneous techniques and operative repair. Transforming the discipline of trauma surgery, Can J Surg, Oct, 2011.

“Hemodynamic instability has now become only a relative contraindication with published targets such as the spleen, liver, kidney, pelvis, lungs and all major abdominal vessels (aorta, iliac, renal, lumbar, inferior vena cava). Balloon occlusion of the distal aorta for bleeding pelvic fractures and proximal aorta for cross-clamping is also well established”

As seen in the quote above, the letter also mentions how intra-aortic balloon catheters, IABCs, are being used more and more for stopping bleeding in the abdomen and pelvis. We wrote a post on IACBs a year ago, with a few references, most of them experimental or case reports. Here’s a link to fairly new article on the subject. It seems placing IABCs aren’t that difficult, even trauma surgeons can place them reliably – so maybe resuscitationists can too? That extra IACB trick up your sleeve will transform any ER/OR to a hybrid suite.

Intra-aortic balloon occlusion to salvage patients with life-threatening hemorrhagic shocks from pelvic fractures, Journal of Trauma, 2010.

Brave New World
Back to RAPTOR. The short letter linked to is well worth a quick read, and points toward a slightly braver new world that will be able to improve care of the trauma patient! In this hybrid set-up you don’t need to make the choice between OR and angio, and you’re not stuck with the wrong decision, as you can swap between angio and OR, or use them simultaneously – any way that suits you to get the best possible result.

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