This presentation gives general overview of the concept "Damage Control Approach" including damage control surgery(DCS) and damage control resuscitation (DCR).
2. Definition
Concept of Damage control
Principles/Lethal Triad
Indications of Damage Control
Damage Control Sequence
Complications
Summary
Outline :
3. Definition:
Damage control surgery (DCS) is a form of surgery typically done by trauma
surgeons utilized in severe unstable injuries.
DCS is a treatment strategy of temporization; prioritizing physiological recovery over
anatomical repair. Its use is associated with dramatically increased survival of the
most seriously injured patients.
Damage control resuscitation (DCR) is a newer development within the damage
control paradigm, and describes novel resuscitation strategies aimed to limit the
physiological derangement of trauma patients.
4. “ …keeping afloat a badly damaged ship by procedures to
limit flooding , stabilize the vessel, isolate fires and explosions
and avoid their spreading”
Surface ship survivability, Naval war publication
3-20.31, Washington, DC. Department of defense; 1996
Concept of Damage control
6. “He who fights and runs away, may live to
fight another day.”
– JA Aulls, 1876
Damage Control Approach ?
7.
In 1983, Stone was first to describe the “bailout” approach .
14 patients :
Per-operative correction of coagulopathy
Definitive surgery
1 survivor
17 patients:
OR and packing
Correction of coagulopathy in ICU
Re exploration in OR
11 survivors
9. Principles:
Lethal Triad:
Acidosis, Hypothermia and Coagulopathy
Damage Control Resuscitation (DCR)
Novel resuscitative strategies to limit
physiological derangement
Damage Control Surgery (DCS)
Treatment strategy of TEMPORIZATION by
prioritizing Physiological Recovery before
Anatomical Repair
Four phase strategy
DC0: DCR, RSI, early rewarming and
expedient transport to OR
DC1: Concurrent DCR and DCS
DC2: ICU resuscitation and
stabilization
DC3: Definitive surgery
11. Hypothermia
1. Heat loss by evaporation and conduction
2. Inability to generate heat
Central cause of all derangements.
Normal human body temperature is 35.6–37.8 degrees C with hypothermia being
defined as a core temperature < 35 degrees
The coagulation system is a temperature- and pH-dependent series of complex
enzymatic reactions.
As the patient’s core temperature decreases, so does the body’s ability to stop
bleeding. This is a result of impaired platelet function, inhibition of the clotting
factors, and inappropriate activation of clot breakdown.
12. Metabolic acidosis
Healthy individual maintains a physiologically normal pH of 7.35–7.45 . Acidosis
is defined as an arterial pH < 7.35
In trauma patients the major contributor is poor perfusion to the tissues. Acute
blood loss, peripheral vasoconstriction and low cardiac output impair oxygen
delivery to the tissues. Anaerobic system is activated in return and lactic acidosis
produced.
Additional cause of acidosis in the trauma patient is excessive resuscitation using
unbalanced crystalloid solutions such as normal saline (pH 5.5)
Another harmful effects of acidemia is that coagulation system can become
severely impaired. In one study, the function of coagulation system was reduced
by 55–70% when the pH dropped from 7.4 to 7.0.
13. Coagulopathy
Consumption dilution
Dilutional coagulopathy occurs when we resuscitate a bleeding trauma patient
with fluid or blood products that don’t contain the same clotting factors.
Hemorrhage
Hypothermia
Acidosis
14. Indications:
Massive Blood Transfusion
>10 unit PRBC
Severe Metabolic Acidosis
pH< 7.30
Hypothermia
<35 degree C
Operative time
>90 mins
Coagulopathy
Either on lab results or ‘non surgical’ bleeding
Lactate
>5 mmol/L
15. STANDARD SURGICAL APPROACH
DAMAGE CONTROL APPROACH
- pH below 7.2
- Core temperature below 32/ 34 C
- More than 5 transfusion
?
Do not wait !!
16. DC0: DCR / Rapid assessment
Extends from pre-hospital setting to ER
DCR
Consist of
<C>ABC (RSI)
Permissive hypotension
Limitation of crystalloid and early
transfusion
Early use of TXA
Gaining large bore IV access
Prevention of hypothermia
Rapid assessment of trauma
Expedient transport to OR
Early use of Blood and Blood products
Massive transfusion protocol
Prevent delay in accessing blood
Imaging
RSI f/b chest x-rays
Pelvic binder
If stabilized CT scan
Primary and secondary surveys
17. DC1: Concurrent DCR and DCS
Objectives
Hemorrhage control
Limitation of contamination
Temporary abdominal closure
Preparation
OT prepped before taking patient
Cruciform position
Prepped from chin to mid thigh
NG, Foley
Don’t delay for central line
Incision
Midline laparotomy
Incision should be made
from Xiphoid to Pubis.
18. DC1 cont…
Hemorrhage control:
Large clots removed manually. Only
expanding hematomas require evacuation.
Non-expanding should not be touched and
may be treated with packing.
Retract and pack each quadrant
sequentially.
Vessels which cannot be ligated without
loss of life or limb can be treated with
temporary indwelling shunts.
If there is continued haemorrhage with packs
in place, aortic control may be necessary.
19. DC1 cont…
Hemorrhage control:
Solid organ injuries:
Prolonged repair to be avoided
Splenic, Renal and Pancreatic injuries
best by partial or total resection
Liver bleeding is managed by Peri-
hepatic packing and tropical hemostatic
agents.
Consider angio-embolization whenever
available
20. DC1 cont…
Abdominal closure:
Fascial closure not
recommended
Temporary closure to avoid
IAH/ACS
Abdominal packing:
sufficient to provide
tamponade but not
impeding vascular return or
arterial supply.
Contamination control:
Control spillage of intestinal content and
urine.
Simple bowel perforation in limited number
may be repaired, else resection.
Reconstruction, stoma creation and feeding
tube avoided.
Biliary/ Pancreatic duct injury: controlled
fistula.
Bladder injury: Primary suturing with foley
drainage.
21. DC2: ICU resuscitation and stabilization
Goal:
Reverse hypotension related metabolic
failure
Support physiological and biochemical
restoration
Normalize lactate within 24 hrs
Aggressive Core Rewarming
Improves perfusion and reverses
coagulopathy.
Passive and Active techniques
Correct Coagulopathy
FFP, Platelets and Cryoprecipitate
Complete physical examination
and relevant imaging
Repair planning
Usually require 24 to 36 Hrs
Unplanned re-operation:
Ongoing transfusion despite
normal clotting and core temp.
ACS: sustained or repeated IAP
>20 mm Hg + new
single/multiple organ failure
23. DC3: Definitive surgery
Maximum impact on achieving successful
outcome
Normothermic, normal coagulation, pH and
lactate (24 – 36 Hrs)
Operative game plan
Handover (if different surgeon)
Irrigate packs to avoid clot disruption
Complete re-examination and definitive
repair
Additional sites of bleeding controlled,
vascular repairs done and intestinal
continuity is restored.
Abdominal closure
Formal abdominal closure
without tension should be
done.
If airway pressure >10 cm H2O
temporary closure to be done
Can be closed within 1 week
26. COMPLICATIONS OF DCS:
Expected complication rate from damage control ranges from 25% to 40%.
Failure to recognize Non-coagulopathic hemorrhage which leads to exsanguination.
Abdominal compartmental syndrome which leads to multi organ failure.
Formation of enteric fistulas esp. in pts with M.O.F and open abdomens for a long
time,
ARDS, intra-abdominal abscesses, sepsis
Mortality at 60%.
27. The management of exsanguination requires leadership, prompt thinking
and aggressive surgical intervention.
Delays in the decision to perform DC contribute to a higher morbidity and
mortality.
DC is a vital part of the management of the multiply injured patient and
should be performed before metabolic exhaustion.
Summary