As stated earlier, in the hypotensive patient with signs of active hemorrhage, immediate operative control of ongoing bleeding is indicated. In this case, a laparotomy and/or thoracotomy must be performed before any intracranial procedures. Once the thoracic and/or abdominal hemorrhage is controlled, any indicated cranial procedure can be started during the same trip to the OR. Close communication between the general surgical, neurosurgical, and anesthesia teams is essential to respond to the rapidly changing physiology of major trauma patients in the operating room.

A polytrauma patient may present with head injury and an extremity injury needing surgical repair. It has been demonstrated that patients with closed femur injury who undergo early repair of the femoral fractures receive more fluids and have worse neurological outcomes [14]. The worse outcomes are thought to be caused by hypoxia or hypotension during early surgery leading to increased secondary brain injury. However, a delay in surgery can lead to increased rates of pulmonary complications including pneumonia and acute respiratory distress syndrome [15]. It is recommended that priority of treatment goes to management of the head injury. Orthopedic injuries should be treated as soon as is safely possible. In all such cases, care must be taken to avoid hypotension and ICP surges during the orthopedic procedure. It is recommended that the neurosurgeon specifically discuss these issues with the Anesthesia and Orthopedic team prior to clearing the patient for surgery.

Cervical spine immobilization is critical for all trauma patients. Cervical spine instability can result from either a spine fracture or ligamentous injury. This instability may lead to misalignment or subluxation of the spine, which can cause compression of the spinal cord or nerves. This may lead to permanent neurologic injury, which can be prevented by use of proper precautions. The cervical spine is the most mobile portion of the spine and cervical collars are used to maintain alignment and prevent subluxation. Avoiding hyperextension or hyperflexion should be a priority especially during intubation. Often airway obstruction can be cleared using a jaw thrust or chin lift maneuver. Endotracheal intubation can be performed in a neutral position and if necessary, a cricothyroidotomy can be performed. The thoracic and lumbar spine are also susceptible to instability and injury and so log rolling precautions should be used when moving the patient to prevent possible further injury. A high quality CT of the cervical spine read as normal by a qualified reader makes it extremely unlikely that there is a significant instability [16].

The proper positioning of the patient in the operating room is necessary to allow each team to have adequate access to the patient. In rare cases a patient may require a craniotomy simultaneously with a laparotomy or a thoracotomy . In these situations, it is important to position the patient so that the neurosurgery team has access to the head. In addition, the patient position must allow the anesthesia team to have access to the airway and intravascular lines. Fortunately, the supine position used for most laparotomies is also compatible with the position used for a trauma craniotomy . The lateral position if needed for a thoracotomy may be more challenging. It is crucial that the neurosurgical, trauma, and anesthesia teams discuss positioning issues prior to the sterile prep and drape of the patient. In a single-center survey of 29 general surgeons and 12 neurosurgeons, Hernandez found that 82 % of general surgeons and 100 % of neurosurgeons found a “hybrid” craniotomy/laparotomy position acceptable for simultaneous procedures [17]. Maintaining a neutral neck position is necessary if spinal instability has not been ruled out.