DAMAGE CONTROL APPROACH

Usama SaeedHouse Surgeon, Surgical Unit ISIMS/Services Hospital, Lahore

Definition Concept of Damage control Principles/Lethal Triad Indications of Damage Control Damage Control Sequence Complications Summary

Outline :

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.

“ …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

Definitive Surgery Approach?

“The operation was a success but the patient died anyway.”

– Anonymous

“He who fights and runs away, may live to fight another day.”

– JA Aulls, 1876

Damage Control Approach ?

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

Why Damage Control?

“It is better to cure in more phases than to kill in

one …”

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

The Lethal Triad

Hypothermia

1. Heat loss by evaporation and conduction2. Inability to generate heatCentral 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.

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. 

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

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

STANDARD SURGICAL APPROACH

DAMAGE CONTROL APPROACH

- pH below 7.2- Core temperature below 32/ 34 C- More than 5 transfusion

?

Do not wait !!

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

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.

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.

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

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.

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

Temporary Abdominal Closure

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

Definitive Repair

Outcome

Before After

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%.

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

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