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Trauma Services:

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natasha bawse

on 7 November 2013

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Transcript of Trauma Services:

Created By: Natasha Henderson, CST

Duke University Hospital

Trauma Services:
Neuro Edition

The new Duke On-Call Policy for the Operating Room (O.R.) staff became effective August 2013.
In an attempt to adjust to this change, this teaching tool has been created to help educate staff and assist in the learning curve



The new Duke On-Call Policy for the Operating Room (O.R.) staff became effective August 2013.

In an attempt to adjust to this change and assist in the learning curve, this teaching tool has been created to help educate staff about different services since currently, the OR is divided into specialties


Educate staff about certain Neurosurgery cases

Discuss prioritization and preparation for the Neurosurgery case set up, for quality patient care

Review necessary/required instrumentation

Review setups for Craniotomies, Subdural Hematomas and Aneurysm Clippings

Types of Cases Discussed

Subdural Hematoma
Aneurysm Clipping


Case/Emergency Case Carts
Positioning/Room Set Up
Back Table Set Up
Prep Table
Drugs on the Field


A craniotomy is a surgical procedure in which a bone flap is created and temporarily removed to access the brain.

Patients may suffer from brain lesions, aneurysms, traumatic brain injury (TBI), and other treatments, i.e. deep brain stimulation

Emergency Case Carts

A Neuro emergency case cart (N319) is located in the Duke Medical Pavilion (DMP), in sterile core A, across from room #45.

There is a Craniotomy basket with items already pulled for an emergency located on the top of that case cart.
Also check surgeon’s preference card

There are two emergency case carts at Duke North (DN) for PEDS Neuro:

Currently, PEDs Crani (N519) and PEDs Shunt (N512SHUNT) are both located across from P2.

Positioning/Room Set Up

The location of the incision on the patient’s head (frontal, parietal, temporal, or occipital) and which side of head (left or right) determines how the patient will be positioned (supine, lateral, or prone) for surgery.


The patient's head is stabilized in a head rest (Mayfield) before the procedure begins. To ensure that maximum exposure to the operative site is created, the surgeon may help with positioning.

Use the appropriate bed and attachment i.e. Berchtold, Fukushima, etc.

Nursing staff will…

Assist with patient positioning onto the OR table
Assist with pressure point padding
Assist with patient comfort and security, i.e. give a warm blanket and use Safety Belt across patients thighs to secure patient to OR table
Put on SCDs if indicated

Room Set Up

Make sure all equipment is available and functional

If the incision is on the right side of the head, the base of the over-bed table is on the right.

If the incision is on the left side of the head, the base of the over-bed table is on the left.

Another option is to have the table off to the side of the patient.

The over bed table must have the extension pulled out and the basin set is opened onto the three-quarter table.

Base of Table on the Right

Know the operative side/site because the over-bed table may need turning for the set up.

Open the salt water basin right after the back table pack is opened so that the circulator can open sterile supplies there
Base of Table on the Left

Back Table Set Up

Down Sheet


Neuro Patties

Neuro Hooks
with two rubber
bands each
Silver Bipolar

Drill Bits


Raney clip appliers
with blue clips

Back Table Set Up

First Row: Scissors
Suture Scissors
Second Row: Penfields

From Neuro Adult Tray

Back Table Set Up

Third Row: Micro Dissectors
Found in Crani Specials and Dr.F Secondary Tray and are used with the Microscope

Fourth Row: Suction Tips
Suction tips from Adult Neuro from Crani Specials and Dr. F Secondary

Fifth Row: Graspers



More instruments are underneath here
(micro i.e. wee scissors, jewelers forceps, dissectors, etc)
Crani Specials

The trays needed for a Craniotomy are:
Adult Neuro (or PEDs Neuro)
Craniotomy Specials
Lorenz Self -Drilling Plating System
A Drill (Xmax or Emax)
Surgeon Specific Trays

Dr F. Secondary

Make sure Drill has appropriate attachment

Crani Silver Glides

Dr. F. Secondary
Lead may be used and put
on patient’s forehead
Prep Table (unsterile)

First, a pre-prep is performed. The nurse can prepare this table with necessary items

During the pre-prep, the resident usually cuts the patient’s hair and then the scalp is cleaned.

If brain lab is indicated, have those instruments (wand) and the brain lab balls
Prep Tables

Pre Prep Table (unsterile)

Table items include:
a comb
silk tape
bacitracin ointment
1010 drape
a lead
hand scrub brush
and a marking pen
Prep Table (Sterile)

The sterile prep-table consists of alcohol, a Chloraprep stick, ten Ray-tecs, five towels, two light handles (one regular and one camera light handle), Chlrohexidine (hibiclens), a sponge stick, a marker, a stapler, and prep gloves

Label all the solutions/drugs on the field

Set the prep table up as soon as possible to optimize the surgeons ability to get started immediately

Usually after the prep, the time out is initiated

Only the sponges, neuro patties, cottonballs, sharps, and small other miscellaneous items are counted in a Crani, (no instrumentation)

Counts are preformed before incision is made
During a level one, the counts may be omitted, per Duke Hospital Policy.

Nevertheless, a count still can be performed if there is enough time

Drugs on the Field

Local injection
Bone wax
Thrombin/gel Foam
Lactated Ringers
Bacitracin ointment


Pitchers are for Lactated Ringers
irrigation with and without Bacitracin
Have bowls ready to receive drugs

Big bowl is for Thrombin and cut up gel foam

Little bowl is for local injection
Thrombin/gel foam, Surgicel and patties
should be ready before the surgery begins

Put plastic over a towel for patties

Have tack up sutures pre loaded per
surgeon preference

Drugs on the Field

Thrombin/gel Foam
Surgicel- cut into various sizes, place on towel

After prepping, the head is draped with:

stapler (if preferred),
Crani drape,
one or two Large drape sheets,
and two Allis’

Drapes are set up on the Mayo stand


For Nurses…

After the time out and draping, over bed table needs to be cranked up and pulled over the patient

Cautery, suction, the drill, and the surgeon’s head light will need to be hooked up and ready for use

Notify the patient’s family that the case has started
Document start times in computer

After draping, hand the surgeon the toys
The “toys” consist of 1 bovie and scratch pad, 2 suctions with silastic tubings attached, 1 silver bipolar to start and two security clamps
Learn how to prioritize. In an emergency Crani, prioritize by knowing what they are going to use first: a blade, bovie, suction, and drill.
So, when you get your instrument trays up pull out:
Knife handles
Silver tip bipolar
Suction tips
Raney clips and hooks.
Load the Blades

The scrub sets the drill up on the field and cover
with towels while the surgeons are setting up the “toys”

Use an Allis to secure drill to drapes

After all the "toys" have been set up, the surgeon may inject a local injection (check preference)

The incision is made with a #10 blade (outside knife). Have raytecs immediately available
Bentback retractors may be used initially for retraction.

A Cushing retractor may be used as well.

Raney clips may be applied to the scalp edges and will remain through out the procedure to aid in hemostasis

Neuro hooks with two rubberbands may replace the bentbacks for retraction

The Bovie and bipolar are for hemostasis and to help cut through tissues to expose the skull

To strip the pericranium from the skull, for drilling, a periosteal elevator (Round or Key) may be used

Either the perforator or the M8 drill bit is used to drill the skull to create Burr holes.

Burr holes are the creation of holes in the skull

Here’s the MH Diamond head drill bit with attachment;
always check surgeon’s preference card

Always have irrigation available during drilling to reduce bone dust from entering the air.

A currette may be used to remove debris and to enlarge the burr holes that were created.

If necessary, Rongeurs and or Kerrisons may be used to excise more bone.
Have bone wax available to aid in hemostasis. Put bone wax in warm solution so that it softens up.

Now the dura will be exposed.

The dura or dura mater is the tough fibrous membrane that envelops the brain.

A Penfield is used to help loosen the dura from the skull.

Once the burr holes are created, and the dura is loosened from the skull,
the drill is changed from perforator/M8 to the A-CRN and foot plate attachment

The A-CRN and footplate are used to cut the skull between the burr holes, therefore, creating the circular bone flap.

The bone flap is put in a basin containing ringers and Bacitracin and soaked.

It is kept in a safe location on the back table.

After the bone flap is off, the dura is lifted away from the brain.

One technique that is used is to use a Dural hook which is created using a TB syringe with its hypo bent at a 90 degree angle at the tip

The 15 blade (inside knife) also is used with Dural pick ups and the incision is extended with either metz or stevens

After all the "toys" have been set up, the surgeon may inject a local injection (check preference)
The incision is made with a #10 blade (outside knife). Have raytecs immediately available
Tack up sutures (4-0 silk pops) may be used to suture the dura out of the field.

The brain is now exposed

Hemostasic Agents are:
Surgicel cut in little pieces/various sizes
Neuro Patties
Gelfoam soaked in thrombin
Bone wax

Once the brain is exposed, the bipolar is switched out from long silver to the short blunt silver glides.
The Frazier tip suction is also switched from. #10 to a #7.

Have ringers irrigation available in 20ml syringes with irrigator tips attached. A variety of hemostasis agents should remain available throughout the case. Once the neuro patties are used, place them in the white basin until they are ready to be counted.


After locating the source of the problem, surgeons work hard to fix it. Once everything is under control and the patient is stable, the wound is irrigated with bulb syringes.

Then it’s time to close.

After the dura is closed, bacitracin can be used for irrigation

The dura is closed with silk sutures

Holes are drilled into the bone flap (use hole maker attachment and ACRN)

Tack up sutures are placed in the dura, then threaded through those holes and will tie the bone flap back into place.

The Lorenz self-drilling screws are used to reattach the bone flap to skull

Then 2-0 Vicryl GS-10 sutures are used to stitch muscle and subcutaneous layers.

The skin is closed with staples and dressing may include a head wrap dressing
(xeroform, gauze, ABDs, kerlex, tape) or just gauze and tegaderms.

Set dressings up neatly on mayo stand and remain sterile along with the back-table until the patient leaves the room.

Let’s Recap:
Open Pack
Down drape( bigger one)
Set basin set up on 3/4 table
Warmer drape
Drape mayo
Arrange gowns and towels on mayo
Put Drapes and Ioban on Mayo
Set up Prep Table

Set bowls out for drugs; lidocaine, thrombin/gelfoam. No bacitracin on the brain.
Put dressings under water basin

Put blades on. Always have two blades loaded; one for scalp (10 blade) and the other one for internal use (15 blade).

Fix package/toys:1 bovie,1 bipolar  (long silver),  two suctions w/ #10 suction tips x2; Put in white basins

Ioban, Crani drape, 2 allis' and up drape, table goes over pt, hand table clamp from FDR, arm, get drill set up cover with towels, set up suctions bovie , give local (if applicable).

Raney clips
Drill M8 (or perforator)
Bone wax
Drill ACRN foot plate
Change bipolar
Change suction from #10 to #7
Drill hole maker
4-0 tack ups irrigate

Subdural Hematoma

A subdural hematoma is a collection of blood that has formed under the dura.

Traumatic head injury or ruptured blood vessels may cause a subdural hematoma to form.

Any pressure on the brain from within the skull can potentially damage the brain itself.

The skull does not expand. Therefore, the hematoma must be located and removed to relieve pressure off the brain.

Remember, the Neuro emergency case cart located in the Duke North Medical Pavilion (DMP), in sterile core A, across from room #45.

There is also a Subdural basket with items already pulled for an emergency located on the top of the case cart.

The room, back-table set up, and surgical technique are, in essence, just like a Craniotomy up until the burr holes are created.

After the burr holes are created and the bone flap is off, the bleeder is found and repaired. Or…

…after the burr holes are created a Red Robinson may be inserted into the burr holes and the area is irrigated thoroughly (no bone flap)

Have suction available. Lots of irrigation in bulb syringes, syringes with a neuro adapter, or a blunt tip may be used to help clear the traumatized area of blood. The bleeding area is located, controlled, and then closed


Aneurysm Clipping

An aneurysm clipping is a procedure done to prevent strokes

An aneurysm is the result of a weakened blood vessel that presents as a blood filled, balloon-like bulge in the wall of a blood vessel

As an aneurysm grows, it becomes thinner and weaker increasing its chance to rupture. The surgeon will place a tiny clip (sort of like a cloths pin) across the neck of the aneurysm to stop or prevent bleeding

The room, back-table set up, surgical technique and
emergency case cart (N319), are, in essence, just like a Craniotomy.

When there is an emergency aneurysm clipping, the surgeon may request the microscope.

Depending on the location and size of the aneurysm,
the surgeon may choose to wear only the loupes.
Always ask the surgeon about what he needs before the procedure.

Clip Appliers and Removers

Aneurysm Clips

Gold clips are temporary
Silver clips are permanent
Dip the clip in Ringers before giving

Drugs on the Field

Local injection
Bone wax
Thrombin/gel Foam
Lactated Ringers
Bacitracin ointment
Muslin and Cotton Wisps

The Experts

Duke Hospital has a strong Neuro Team.

On different occasions, I have consulted with Grace Fabito (clinical lead), Theresa Cordero,
Kathy Bolyard, Theresa Williams, Erica Edge, and many others who work in Neuro to help me learn this service.

They have been willing to teach anyone who wants to learn. Kudos Neuro Team!


I also have to mention Joanne Galli, the second shift charge nurse.

When I was attempting to learn new services, Joanne became my very best resource.

In the evenings after my cases were done, I would go and ask her what cases were still going. Joanne would always let me choose a case to observe or to scrub in on. Kudos Joanne!

Trauma Services: Neuro Edition
How Effective was this Teaching Tool?

Cross Training

This presentation was initially presented to Urology/GYN Services.

Pre and post test statements and were given to determine
their knowledge base before and after this presentation.

And the results are in…

S#1: I know the most common reasons for a Craniotomy

S#2: I know the most common
reasons for a Subdural Hematoma

S#3: I know the most common reason for an Aneurysm Clipping

S#4: I know where the Adult Neuro emergency case cart and supplied are located

S#5: I know the instruments required for a Craniotomy

S#6: I know how many emergency Pediatric case carts there are and where they are located

S#7: I know how to set the back table up for a Craniotomy

S#8: I understand the procedure for a Craniotomy

S#9: I am aware of the drugs that are used in a Craniotomy

Summary of Pre and Post Statements

Summary Pre and Post Statements

Question #5,
S#5: I know the
instruments required for a
was the least
I know the most common
reasons for a Subdural Hematoma,
was the most known/learned.
Thank You for Watching!
Full transcript