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Damage Control Surgery

Sanda Pudule

Supervisor: Ruta Jakušonoka

22.11.2016., Rīga

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Definition;History;The Lethal triad;Stages of damage control surgery;Damage Control Orthopedics;Complications of Damage Control;Case report;Conclusion;

Table of Contents

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Damage control surgery (DCS) is a concept of abbreviated laparotomy, designed to prioritize short-term physiological recovery over anatomical reconstruction in the seriously injured and compromised patient.[1]

Definition

[1] http://bja.oxfordjournals.org/content/113/2/242.full

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Damage control – military term used to describe a ship’s ability to maintain its mission after being damaged.

1983 – first published papers on the matter of damage control;

1993 – first adaption clinically, by Schwab et al

History

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3908997/

http://forums.motortrend.com/70/7513720/the-drive-in/what-did-the-us-navy-d

o-better-then-everyone-else/index.html

(Ilustrations)

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HypothermiaCoagulopathyMetabolic acidosis

The «Lethal triad»

http://www.jems.com/articles/print/volume-39/issue-4/features/trauma-s-lethal-triad-h

ypothermia-acidos.html

(Ilustrations)

6http://www.jems.com/articles/print/volume-39/issue-4/features/trauma-s-lethal-triad-hyp

othermia-acidos.html

(Ilustrations)

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Result of severe exsanguinating injury and subsequent resuscitative attempts.

Severe haemorrhage leads to an inability to generate heat.

Clinically significant:»360C – more than 4h;

»320C – 100% mortality rate;

Hypothermia

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Occurance of:»Cardiac arrhythmias;

»Reduced cardiac output;

»Increased systemic vascular resistance

»Shifting of the oxygen-dissociation curve to the left;

Immune system – suppressed;Bleeding is increased due to:

»Disfunction of coagulation factors;

»Platelet dysfunction;

»Abnormalities, alterations in the fibrinolytic system;

Hypothermia

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Dissbalance between heamostatic and fibrinolytic systems;

Hypothermia reduces metabolic rate of coagulation factors;

Clinical dg:»Non-surgical bleeding from wounds, serosal surfaces,

vascular access sites, skin edges.

Laboratory dg:»Fibrinogen levels, Protrombine time, partial protrombine time

Coagulopathy

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Prolonged hypoperfusion -> anaerobic metabolism ->lactic acidosis

Results:»Contractility of myocard is decreased, leading to reduction of

cardiac output.

»Coagulation factors are inactive because of acidic environment.

Metabolic acidosis

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Stage I: abbreviated resuscitative surgeryStage II: CCU* resuscitation

»Hypothermia

»Coagulopathy correction

»Correction of acidosis

Stage III: definitive surgery

Stages of damage control surgery

*Critical Care Unit

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Control of hemorrhages;Control of fecal spillage (to minimise contamination);Packing;Temporary abdominal closure;External fixation, splinting (to immobilize);

Stage I: abbreviated resuscitative surgery

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Re-warming the patient (370C within 4h);Control metabolic acidosis (recorrects itself);Treat coagulopathy (the 10 unit rule);End organ support;

Stage II: CCU resuscitation

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Within 36-48h;Gastrointestinal continuity;Abdominal closure;Definitive stabilization of fractures, other injuries;

Stage III: definitive reconstructive surgery

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StabilizationStaged definitive management

»Initial pelvic volume reduction (sheet, pelvic packing, external fixation etc.)

»Hemodynamically stable -> CT imaging

»Hemodynamically unstable -> pelvic angiography and embolization

Definitive treatment»After 5 days

Damage Control Orthopedics

http://www.orthobullets.com/trauma/1005/evaluation-resuscitation-and-dco

H.C.Pape et al.”Damage control management in the polytrauma patient” Springer, 2010.

Pape HC, Sanders R, Borelli J, editors. The Poly-Traumatized Patient with Fractures. A Multi-

Disciplinary Approach. Berlin, Heidelberg: Springer - Verlag; 2011.

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Clinical parameters:»pH 7.2 or less;

» intra-operative core temp.340C or less;

»Transfusion volume or packed RBCs 4000 ml or more;

»Total blood replacement 5000ml or more;

»Total fluid replacement 12 000ml or more;

Physiological parameters:»High energy, blunt torso trauma;

»Multiple torso penetrations;

»Hemodynamic instability;

»Coagulopathy and/or hypotermia on admission;

When to initiate damage control?

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Wound infection;Abdominal abscess;Wound dehiscence;Bile leak;Enterocutaneous Fistula;Abdominal Compartment Syndrome;Multisystem Organ failure;Mortality;

Complications of Damage Control

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Case reportby Mayr J et al.

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Damage Control Resuscitation in a 12-Year Old Girl with Severe Thoraco-Abdominal Polytrauma

http://trauma-acute-care.imedpub.com/damage-control-resuscitation-in-a-12year-

old-girl-with-severe-thoracoabdominal-polytrauma.pdf

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Damage Control Resuscitation in a 12-Year Old Girl with Severe Thoraco-Abdominal Polytrauma

http://trauma-acute-care.imedpub.com/damage-control-resuscitation-in-a-12year-old

-girl-with-severe-thoracoabdominal-polytrauma.pdf

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Damage Control Resuscitation in a 12-Year Old Girl with Severe Thoraco-Abdominal Polytrauma

http://trauma-acute-care.imedpub.com/damage-control-resuscitation-in-a-12year-ol

d-girl-with-severe-thoracoabdominal-polytrauma.pdf

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Damage control surgery is administered to critically ill patients. The most common causes of death for trauma patients include head injury, blood loss and multiple organ failure. These causes account for 30-40% of trauma related deaths (Duschene, 2010). The technique used during the surgery is designed to preventing the ‘lethal triad’. The trauma triad of death refers to the combination of hypothermia, acidosis and coagulopathy.

Conclusion

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Damage control surgery prioritizes short-term physiological recovery over anatomical reconstruction in the seriously injured and compromised patient. The use of DCR has been associated with improved outcomes for the severely injured and wider adoption of these principles where appropriate may allow this trend of improved survival to continue.

Conclusion

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https://www.youtube.com/watch?v=J6Zz0I6sfaM S.S. Jaunoo*, D.P. Harji, Department of General Surgery, Worcestershire Royal Hospital,

Charles Hastings Way, Worcester WR5 1DD, United Kingdom, Damage control surgery, International Journal of Surgery 7 (2009) 110–113, 2009.

http://bja.oxfordjournals.org/content/113/2/242.fullhttp://trauma-acute-care.imedpub.com/damage-contro

l-resuscitation-in-a-12year-old-girl-with-severe-thoracoabdominal-polytrauma.pdf

References

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http://www.medscape.com/viewarticle/829159https://www.ncbi.nlm.nih.gov/pmc/articles/

PMC3908997/http://www.orthobullets.com/trauma/1005/evaluation-

resuscitation-and-dcohttp://www.slideshare.net/bashirbnyunus/damage-

control-surgery-44230609

References

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H.C.Pape et al.”Damage control management in the polytrauma patient” Springer, 2010.

Pape HC, Sanders R, Borelli J, editors. The Poly-Traumatized Patient with Fractures. A Multi-Disciplinary Approach. Berlin, Heidelberg: Springer - Verlag; 2011.

References

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Thank You for Your attention!