damage control in the patient in shock: medical and surgical therapies ana navÍo m.d. ph.d....
TRANSCRIPT
DAMAGE CONTROL IN THE PATIENT IN SHOCK MEDICAL AND SURGICAL THERAPIES
ANA NAVIacuteO MD PhDEMERGENCY DEPARTMENT LA PAZ UNIVERSITY HOSPITAL MADRID SPAIN
IT IS ALWAYS BETTER SMILING
bull 1) HISTORICAL NOTES
bull 2) CURRENT CONCEPTS
bull 3) SO NOW WHAT
SHOCK is a state of compromised tissue perfusion that causes cellular hypoxia
It is a syndrome initiated by ACUTE HYPOPERFUSION leading to tissue hypoxia and vital organ dysfunction
Shock is a SYSTEMIC DISORDER affecting MULTIPLE ORGAN SYSTEMS
During shock PERFUSION IS INSUFFICIENT to meet the metabolic demands of the tissues
CELLULAR HYPOXIA and end ORGAN DAMAGE
Principle of Medicine
PRIMUM NON NOCEREldquoFirst do no harmrdquo
Hippocrates
ldquoDamage Control Resuscitation represents the most important advance in trauma care for hospitalized civilian and military casualties from this warrdquo
Cordts Brosch and Holcomb J Trauma 2008
His surgical technical was modified by HALSTED in 1913Garciacutea-Nuacutentildeez L Cabello R Lever C Rosales E Padilla R Garduntildeo P et alConceptos Actuales en Cirugiacutea Abdominal de Control de DantildeosComunicacioacuten acerca de donde hacer menos es hacer maacutes Trauma 2005 8 76-81
The abdominal packing has been the basement for the damage control surgery and the first phisician (military surgeon) who reported was PRINGLE in 1908
Pringle JH Notes on the arrest of hepatic hemorrhage due to trauma Ann Surg 1908 48541-9
bull In 1955 MADDING studied the temporal packing in hemorragic control after abdominal surgery
bull The MODERN era of damage-control laparotomy began with the seminal report of STONE ET AL from the Grady Memorial Hospital Atlanta Ga in 1982
Stone H Strom P Mullines R Management of the major coagulopathy with on set during laparotomy Ann Surg 1983 197532-535
bull The concept of damage control was introduced by ROTONDO y SCHWAB in patients with dangerous abdominal trauma described the three times in this surgery
Rotondo MF Mc Gonigol MD Schwab CW Kauder DR Hanson CW Damage Control An approach for improved survival in exsanguinating penetrating abdominal injury J Trauma 1993 35375-83
New Diagnostic criteriaAvoids the ldquobut he looked goodrdquo phenomenon
Within the first five minutes in the ED
Identify patients in trouble
Identify patients with increased mortality
Identify patients with increased probability of massive transfusion
The CONDUCT OF DAMAGE-CONTROL LAPAROTOMY has been described in detail elsewhere we can view the process in STAGES
Germanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis N Damage control surgery in the abdomen an approach for the management of severe injured patients Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13Lee JC Peitzman AB Nuffield Department of Surgery John Radcliffe Hospital Oxford UK Damage-control laparotomy Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA Curr Opin Crit Care 2006 Aug12(4)346-50
The MORE IMPORTANT PHASE is to IDENTIFY the appropriate candidate
bull Acidosis- Base Deficit gt - 6 phlt 72bull Coagulopathy INR gt 15 or TTPA gt 60 scbull Hypotension Systolic BP lt 90 mmHgbull Need of transfusion gt 4 l red cell contentsbull Temperature lt 96 5 F=34 Cbull Pattern recognition
bull Weak or absent radial pulse bull Abnormal mental statusbull Severe Traumatic Injury
DEATH
HYPOTHERMIA
ACIDOSIS
COAGULOPATHY
The Lethal TriadThe Lethal TriadThe Lethal TriadThe Lethal Triad
Soto S Oettinger R Brousse J Saacutenchez G Cirugiacutea de Control de Dantildeos Enfrentamiento actual del Trauma Cuad Cir 20031795-102
The OBJECTIVES are
1) STOP HEMORRHAGE to correct underlying coagulopathy
2) MINIMIZE PERITONEAL CONTAMINATION and its secondary inflammatory response
3) ENCLOSE THE ABDOMINAL CONTENTS to protect viscera and minimize protein loss
4) The final objective of this damage-control phase is CLOSURE OF THE ABDOMINAL CAVITY
bullRequires robust MEDICAL SETTING
bullNeed system approach to deliver casualties to MOST CAPABLE FACILITIES
bullIsolated and far forward facilities can still benefit from these principles
AcidosisAcidosisBASE DEFICIT (BD) ge -15 identifies patients that require early
transfusion increased ICU days and risk for ARDS and MOF Ferrara A Mac Arthur J Wright H Hypothermia and Acidosis worsen coagulopathy in the patient requiring massive transfusion Ann J Surg 1990 160515-518
bull BD of ge -15 is strongly associated with the need for massive transfusion and mortality in patients
Rutherford EJ Morris JA Reed GW Hall KS Base deficit stratifies mortality and determines therapy J Trauma 1992 33417-23
bull Patients have an elevated BD before their blood pressure drops to classic ldquohypotensionrdquo levels
bull Acidosis contributes more to coagulopathy more than hypothermia (not reversible)
bull An initial INR ge 15 reliably predicts those who will require massive transfusion
Moore FA Nelson T Massive transfusion in trauma patients tissue hemoglobin oxygen saturation predicts poor outcom J Trauma 2008 Apr 64 (4)1010-23
bull Patients who have a significant injury present with a coagulopathy
bull Severity of injury and mortality is linearly associated with the degree of the initial coagulopathy
Coagulopathy
bull Although resuscitation strategies for severely injured patients who present WITH SHOCK have improved greatly the transfusions are associated with development of MOF and increased intensive care unit (ICU) admissions ICU and hospital length of stay and mortality
bull Malone DL Dunne J Tracy JK Putnam AT Scalea TM Napolitano LM Blood
transfusion independent of shock severity is associated with worse outcome in trauma J Trauma 2003 54898-905
bull Eastridge BJ Malone D Holcomb JB Early predictors of transfusion and mortality
after injury a review of the data-based literature J Trauma 2006 60S20-S25 bull Napolitano L Cumulative risks of early red blood cell transfusion J Trauma 2006
60S26-S34 bull Cotton BA Guy JS Morris JA Jr Abumrad NN The cellular metabolic and systemic
consequences of aggressive fluid resuscitation strategies Shock 2006 26115-121
Current transfusion practices and survival rates of massive transfusion patients vary widely among trauma centers Conventional guidelines may underestimate the optimal plasma and platelet to RBC ratios
Survival in patients is associated with increased plasma and platelet ratios Massive transfusion practice guidelines should aim for a111 ratio of plasma plateletsRBCs bullHolcomb et al Ann Surg 2008248447
Kaplan-Meier survival plot for the first 24 hours after admission for the 4 groups (high plasma (FFPH) or platelet (PltH) to RBC ratio 12 low plasma (FFPL) or platelet (PltL) to RBC ratio 12)
Statistical modeling indicated that a
clinical guideline with mean plasma
RBC ratio equal to 11 would
encompass 98 of patients within
the optimal 12 ratio
Hypotension A systolic blood pressure of 90 mm Hg or less is indicative casualties that have lost over 40 of their blood volume
(~2000 ml in an adult)
They have impending cardiovascular collapse and have significantly increased mortality
The most efficient solution for use in resuscitation is still under debate
Lactated Ringers (LR) and normal isotonic saline solution (NS) remain the
most commonly used isotonic fluids
Although colloid solutions including hyperosmolar colloid and hypertonic
electrolyte compounds have been approved for use as volume expanders
their administration is still under debate in the USA and Europe
Moore FA McKinley BA Moore EE Nathens AB West M Shapiro MB Bankey P Freeman B Harbrecht BG Johnson JL Minei JP Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core standard operating procedures for clinical care III Guidelines for shock resuscitation J Trauma 2006 6182-89 Spahn DR Cerny V Coats TJ Duranteau J Fernandez-Mondejar E Gordini G Stahel PF Hunt BJ Komadina R Neugebauer E Ozier Y Riddez L Schultz A Vincent JL Rossaint R Task Force for Advanced Bleeding Care in Trauma Management of bleeding following major trauma a European guideline Crit Care 2007 11R17
Experimental studies have revealed that resuscitation with NS in the setting of massive hemorrhage requires significantly greater volume and is associated with increased physiologic derangements (for example hyperchloremic acidosis and dilutional coagulopathy) and higher mortality as compared with LR Healey MA Davis RE Liu FC Loomis WH Hoyt DB Lactated ringers is superior to normal saline in a model of massive hemorrhage and resuscitation J Trauma 1998 45894-899 Todd SR Malinoski D Muller PJ Schreiber MA Lactated Ringers is superior to normal saline in the resuscitation of uncontrolled hemorrhagic shock J Trauma 2007 62636-639
Reported data from several studies conducted in critically ill patients have indicated that use of colloid solutions has a significant impact on hemorrhage hemostasis and inflammatory response Roberts I Alderson P Bunn F Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2004 CD000567 Vercueil A Grocott MP Mythen MG Physiology pharmacology and rationale for colloid administration for the maintenance of effective hemodynamic stability in critically ill patients Transfus Med Rev 2005 1993-109 Lee CC Chang IJ Yen ZS Effect of different resuscitation fluids on cytokine response in a rat model of hemorrhagic shock Shock 2005 24177-181
Early administration of blood is one potential treatment to decrease the
need for massive crystalloid solution in hemorrhagic shock however the
limited supply of stored blood and potential adverse effects make this
option logistically difficult and possibly harmful
West MA Sha piro MB Nathens AB Johnson JL Moore EE Minei JP Bankey PE Freeman B Harbrecht BG McKinley BA Moore FA Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core-standard operating procedures for clinical care IV Guidelines for transfusion in the trauma patient J Trauma 2006 61436-439
Moore FA McKinley BA Moore EE Nathens AB West M Shapiro MB Bankey P Freeman B Harbrecht BG Johnson JL Minei JP Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core standard operating procedures for clinical care III Guidelines for shock resuscitation J Trauma 2006 6182-89 Spahn DR Cerny V Coats TJ Duranteau J Fernandez-Mondejar E Gordini G Stahel PF Hunt BJ Komadina R Neugebauer E Ozier Y Riddez L Schultz A Vincent JL Rossaint R Task Force for Advanced Bleeding Care in Trauma Management of bleeding following major trauma a European guideline Crit Care 2007 11R17
Transfusion-related risks include possible development of MOF increased
ICU admissions and length of stay increased hospital length of stay and
mortality
Malone DL Dunne J Tracy JK Putnam AT Scalea TM Napolitano LM Blood transfusion independent of shock severity is associated with worse outcome in trauma J Trauma 2003 54898-905
Eastridge BJ Malone D Holcomb JB Early predictors of transfusion and mortality after injury a review of the data-based literature J Trauma 2006 60S20-S25
Napolitano L Cumulative risks of early red blood cell transfusion J Trauma 2006 60S26-S34
Cotton BA Guy JS Morris JA Jr Abumrad NN The cellular metabolic and systemic consequences of aggressive fluid resuscitation strategies Shock 2006 26115-121
uarr hemorrhage + excessive hemodilution due to
uarr Blood Presion darr blood viscosity darr hematocrit
darr clotting factor concentration
Risks of Aggressive Volume Resuscitation
rFVIIaThe use of rFVIIa was associated with improved early and late survival after severe trauma and massive transfusion
rFVIIa was not associated with increased risk of thrombotic events
The Effect of Recombinant Activated Factor VII on Mortality in Combat-Related Casualties With Severe Trauma and Massive Transfusion
bull Philip C Spinella MD Jeremy G Perkins MD Daniel F McLaughlin MD Sarah E Niles MD MPHKurt W Grathwohl MD Alec C Beekley MD Jose Salinas PhD Sumeru Mehta MD Charles E Wade PhDand John B Holcomb MD J of Trauma- Feb 2008bull Dutton et al J Trauma 200457709 Conclusion consider early use of FVIIa in any pt with uncontrolled hemorrhage who has not responded to surgery or blood component therapy
bull Each unit of blood product biologically active + elevates risk of infections + ARDS (SDRA)Chaiwat et al Anesthesiology 2009110351 n=14070 pts NSCOT database retrospective
bull Older blood association whith elevates infection LOS MOSF + death Weinberg et al J Trauma 200865279
TemperatureA temperature lt 96degF or 35degC is associated with an increase in mortality (cardiac arrest SRP higher abnormal plaquelet function) Burch J Denton J Noble R Physiologic rationale for abbreviated laparotomy Surg Clin North Am 1997 77779-82 Trauma patients that are hypothermic are NOT PERFUSING their tissue
The COAGULATION CASCADE is an enzymatic pathway that degrades with temperature and ceases at 92 FGregory JS Francbeum L Towsened MC Incidence and timing of hypothermia in trauma patients undergoing operations J Trauma 1991 31795-800 If the temperature is lower than 33 C the mortality is 100although Beilman and col think itacutes a significant factor for MODS but not for the mortalityBeilman GJ Blondet JJ Early hypothermia in severely injured trauma patients is a significant risk factor for multiple organ dysfunction syndrome but not mortality Ann Surg 2009 May249(5)845-50
Diagnosis done
Damage Control Resuscitation
1 Hypotensive resuscitation
2 Hemostatic resuscitation
Damage control philosophy can be extended to haemostatic resuscitation
Restoring normal coagulation Minimizing crystalloidTraditional resuscitation strategies dilute the already deficient coagulation factors and increase multiple organ failure
The aggressive hemostatic resuscitation should be combined with equally aggressive control of bleeding
Spahn DR Cerny V Management of bleeding following major trauma a European guidelineCrit Care 2007 11(1) R 17
WAIT AND SEE
SURGEON
ABDOMINAL PACKING is a lifesaving technique for temporary control of severe injury and it is used in damage control surgery schedule
Its possible too applying packs in organ-specific techniques (early abdominal packing)
The median survival of the 70 certainly superior to the obtainable survival with immediate surgical repairbullIMMEDIATE FAILURES are substantially due to bleeding especially in underpacking caseREMOTE FAILURES septic and bound at the time of stay (above the 72 hours) and associated by the coexistence of lesions in these situations is possible a MOF syndrome due to excessive intra-abdominal pressure (overpacking) or to an Abdominal Compartment Syndrome
Stagnitti F Bresadola L Calderale SM Coletti M Ribaldi S Salvi PF Schillaci F Abdominal packing indications and method Ann Ital Chir 2003 Sep-Oct74(5)535-42
Benavides C Garciacutea C Apablaza S Rubilar P Ricaurte F Perales C et al Empaquetamiento hepaacutetico permanente con malla de poliglactina en estallido hepaacutetico secundario a Siacutendrome de Hellp Rev Chil Cir 2004 56 275-278 De la Fuente M Mendoza VH Robledo-Oyarzun F Cierre Temporal de la pared abdominal con polietileno Cir Ciruj 2002 70157-63 Serna VH El Siacutendrome Compartamental Abdominal Tesis de Postgrado Meacutexico 2000
When skin approximation is
not possible a temporary silo
is constructed by suturing a 3-
L cystoscopy irrigation bag
(BOGOTAacute BAG) to the skin
edge with a continuous No 2
nylon suture
The method of closure depends on whether skin approximation produces excessive intra-abdominal hypertension
Towel-clip closure of the skin is preferred because it is quick and easy
The second phase is intra-operative reassessment for hemorrhage control 30 minutes after initial abdominal closure in the operating room focusing on restoration of the patients physiological status specifically reversing hypothermia and coagulopathy
WE CAN HEAR THE HEMORRHAGE
The abdomen is then reopened and assessed for adequacy of hemostasis and for existence of residual mechanical bleeding This practice has allowed surgeons to minimize both early return to the operating room for ongoing hemorrhage and the amount of packing necessary for hemostasis With bleeding effectively controlled the abdomen is reclosed
The patient is transferred to the ICU for continued physiologic restoration in the third phase
Once coagulopathy hypothermia and acidosis have been corrected the patient can be returned to the operating room for definitive management of the injuries in the fourth phase
48-72 h after first surgery
COMPLICATIONS OF DAMAGE CONTROL LAPAROTOMY
1) ACS Acute Compartmental Syndrome
2) ARDS Acute Respiratory Distress of the Adult
3) MOF Multiple organ failure
4) DEATH
ABDOMINAL COMPARTMENT SYNDROME is defined as an intra-abdominal pressure of greater than 20 cm H2O with evidence of impaired organ function ie elevated peak airway pressures (gt45 cm
H2O) oliguria (lt05 mLkg per hour) or cardiovascular dysfunction
(hypotension despite adequate volume resuscitation or if a pulmonary artery catheter is present oxygen delivery index [calculated as milliliters of oxygen per minute per meter squared] of 600) Intra-abdominal pressure was measured indirectly using an indwelling Foley catheter as previously described
Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13 Damage control surgery in the abdomen an approach for the management of severe injured patientsGermanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis NNuffield Department of Surgery John Radcliffe Hospital Oxford UK Curr Opin Crit Care 2006 Aug12(4)346-50 Damage-control laparotomy Lee JC Peitzman AB Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA
ABDOMINAL COMPARTMENT SYNDROME occurred in 17 (33) of
52 Patients undergoing damage-control laparotomy and was
associated with a much higher incidence of ARDS and MOF (71 vs
31 without ACS P = 02)
More importantly our study suggests that primary fascial closure at
the termination of the initial damage-control laparotomy contributes to
the development of ACS as well as subsequent organ failure
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal ypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
Mayberry JC Mullins RJ Crass RA Trunkey DD Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure Arch Surg 1997132957-962
bull MOF Multiple organ failure
Seems to be a major source of postinjury morbidity and the leading cause of in-hospital mortality despite more than 25 years of intense investigation
Eiseman B Beart R Norton L Multiple organ failure Surg Gynecol Obstet 1977144323-326
Bauer AE Durham R Faist E Systemic inflammatory response syndrome (SIRS) multiple organ dysfunction syndrome (MODS) multiple organ failure (MOF) are we winning the battle Shock 19981079-89
The current pathophysiologic model of MOF focuses on uncontrolled systemic
hyperinflammation as a unifying concept following a variety of insults
Moore FA Moore EE Evolving concepts in the pathogenesis of postinjury multiple organ failure Surg Clin North Am 199575257-277
Goris RJ te Boekhorst TP Nuytinck JK Gimbrere JS Multiple-organ failure generalized autodestructive inflammation Arch Surg 19851201109-1115
Nuytinck HK Offermans XJ Kubat K Goris JA Whole-body inflammation in trauma patients an autopsy study Arch Surg 19881231519-1524
Examples that improve the prognosis of MOF include damage control surgery recognition of abdominal compartment syndrome lung protective ventilation
strategies and tight glucose level control
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal hypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
The Acute Respiratory Distress Syndrome Network Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome N Engl J Med 20003421301-1308
Amato MB Barbas CS Medeiros DM et al Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome N Engl J Med 1998338347-354
Van den Berghe G Wouters P Weekers F et al Intensive insulin therapy in the critically ill patients N Engl J Med 20013451359-1367
The incidence of postinjury MOF has been reported to be between 7 and 66 with an associated mortality rate between 31 and 80
Fry DE Pearlstein L Fulton RL Polk HC Jr Multiple system organ failure the role of uncontrolled infection Arch Surg 1980115136-140
Regel G Lobenhoffer P Grotz M Pape HC Lehmann U Tscherne H Treatment results of patients with multiple trauma an analysis of 3406 cases treated between 1972 and 1991 at a German level I trauma center J Trauma 19953870-78
Sauaia A Moore FA Moore EE Norris JM Lezotte DC Hamman RF Multiple organ failure can be predicted as early as 12 hours after injury J Trauma 199845291-303
Nast-Kolb D Aufmkolk M Rucholtz S Obertacke U Waydhas C Multiple organ failure still a major cause of morbidity but not mortality in blunt multiple trauma J Trauma 200151835-842 Durham RM Moran JJ Mazuski JE Shapiro MJ Baue AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
It has been suggested that MOF is disappearing owing to advances in trauma and critical care
Levine JH Durham RM Moran J Bauer A Multiple organ failure is it disappearing World J Surg 199620471-473
Recent reports have not demonstrated a consistent change in either the incidence or the mortality rate associated with postinjury MOF Some groups have reported no change in the incidence but a decreased mortality while others have reported both decreased incidence and mortality compared with historical control subjects
Durham RM Moran JJ Mazuski JE Shapiro MJ Bauer AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
Regel G Grotz M Weltner T Sturm JA Tscherne H Pattern of organ failure following severe trauma World J Surg 199620422-429
Orthopaedic Trauma
Open pelvic fractures in addition to the pelvic ring injury are associated with hemorrhage and neurological insult visceral injuries are more common and a high rate of infection is seen Mortality of open pelvic fractures historically approached 50 Control of bleeding is the most important initial measure followed by debridement and packing of open wounds
Open book- widened symphysis pubis Dislocated Rt SI joint Vallier + Jenkins In Trauma Anesthesia 2008
Type 1 fractures occur due to anterior-posterior
compressioncan cause the symphysis pubis to ldquopoprdquo open leading to pubic rami or ldquoopen
bookrdquo fractures A lateral compression fracture type 2 or vertical sheer facture (Type 3) can
also lead to severe bleeding Into the pelvis Pelvic and acetabular surgery are major surgical interventions
Figura 1- Aplicacioacuten de la engrapadora para la reseccioacuten pulmonar en cuntildea Los segmentos a resecar se limitan por medio de la aplicacioacuten de dispositivos de grapado orientados en direcciones perpendiculares tratando de mantener la mayor cantidad de tejido sano
Insercioacuten de engrapadora lineal cortante a traveacutes de los orificios del tracto de la herida pulmonar penetrante
Figura 3- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales con fuga aeacuterea visible
Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales
Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
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-
IT IS ALWAYS BETTER SMILING
bull 1) HISTORICAL NOTES
bull 2) CURRENT CONCEPTS
bull 3) SO NOW WHAT
SHOCK is a state of compromised tissue perfusion that causes cellular hypoxia
It is a syndrome initiated by ACUTE HYPOPERFUSION leading to tissue hypoxia and vital organ dysfunction
Shock is a SYSTEMIC DISORDER affecting MULTIPLE ORGAN SYSTEMS
During shock PERFUSION IS INSUFFICIENT to meet the metabolic demands of the tissues
CELLULAR HYPOXIA and end ORGAN DAMAGE
Principle of Medicine
PRIMUM NON NOCEREldquoFirst do no harmrdquo
Hippocrates
ldquoDamage Control Resuscitation represents the most important advance in trauma care for hospitalized civilian and military casualties from this warrdquo
Cordts Brosch and Holcomb J Trauma 2008
His surgical technical was modified by HALSTED in 1913Garciacutea-Nuacutentildeez L Cabello R Lever C Rosales E Padilla R Garduntildeo P et alConceptos Actuales en Cirugiacutea Abdominal de Control de DantildeosComunicacioacuten acerca de donde hacer menos es hacer maacutes Trauma 2005 8 76-81
The abdominal packing has been the basement for the damage control surgery and the first phisician (military surgeon) who reported was PRINGLE in 1908
Pringle JH Notes on the arrest of hepatic hemorrhage due to trauma Ann Surg 1908 48541-9
bull In 1955 MADDING studied the temporal packing in hemorragic control after abdominal surgery
bull The MODERN era of damage-control laparotomy began with the seminal report of STONE ET AL from the Grady Memorial Hospital Atlanta Ga in 1982
Stone H Strom P Mullines R Management of the major coagulopathy with on set during laparotomy Ann Surg 1983 197532-535
bull The concept of damage control was introduced by ROTONDO y SCHWAB in patients with dangerous abdominal trauma described the three times in this surgery
Rotondo MF Mc Gonigol MD Schwab CW Kauder DR Hanson CW Damage Control An approach for improved survival in exsanguinating penetrating abdominal injury J Trauma 1993 35375-83
New Diagnostic criteriaAvoids the ldquobut he looked goodrdquo phenomenon
Within the first five minutes in the ED
Identify patients in trouble
Identify patients with increased mortality
Identify patients with increased probability of massive transfusion
The CONDUCT OF DAMAGE-CONTROL LAPAROTOMY has been described in detail elsewhere we can view the process in STAGES
Germanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis N Damage control surgery in the abdomen an approach for the management of severe injured patients Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13Lee JC Peitzman AB Nuffield Department of Surgery John Radcliffe Hospital Oxford UK Damage-control laparotomy Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA Curr Opin Crit Care 2006 Aug12(4)346-50
The MORE IMPORTANT PHASE is to IDENTIFY the appropriate candidate
bull Acidosis- Base Deficit gt - 6 phlt 72bull Coagulopathy INR gt 15 or TTPA gt 60 scbull Hypotension Systolic BP lt 90 mmHgbull Need of transfusion gt 4 l red cell contentsbull Temperature lt 96 5 F=34 Cbull Pattern recognition
bull Weak or absent radial pulse bull Abnormal mental statusbull Severe Traumatic Injury
DEATH
HYPOTHERMIA
ACIDOSIS
COAGULOPATHY
The Lethal TriadThe Lethal TriadThe Lethal TriadThe Lethal Triad
Soto S Oettinger R Brousse J Saacutenchez G Cirugiacutea de Control de Dantildeos Enfrentamiento actual del Trauma Cuad Cir 20031795-102
The OBJECTIVES are
1) STOP HEMORRHAGE to correct underlying coagulopathy
2) MINIMIZE PERITONEAL CONTAMINATION and its secondary inflammatory response
3) ENCLOSE THE ABDOMINAL CONTENTS to protect viscera and minimize protein loss
4) The final objective of this damage-control phase is CLOSURE OF THE ABDOMINAL CAVITY
bullRequires robust MEDICAL SETTING
bullNeed system approach to deliver casualties to MOST CAPABLE FACILITIES
bullIsolated and far forward facilities can still benefit from these principles
AcidosisAcidosisBASE DEFICIT (BD) ge -15 identifies patients that require early
transfusion increased ICU days and risk for ARDS and MOF Ferrara A Mac Arthur J Wright H Hypothermia and Acidosis worsen coagulopathy in the patient requiring massive transfusion Ann J Surg 1990 160515-518
bull BD of ge -15 is strongly associated with the need for massive transfusion and mortality in patients
Rutherford EJ Morris JA Reed GW Hall KS Base deficit stratifies mortality and determines therapy J Trauma 1992 33417-23
bull Patients have an elevated BD before their blood pressure drops to classic ldquohypotensionrdquo levels
bull Acidosis contributes more to coagulopathy more than hypothermia (not reversible)
bull An initial INR ge 15 reliably predicts those who will require massive transfusion
Moore FA Nelson T Massive transfusion in trauma patients tissue hemoglobin oxygen saturation predicts poor outcom J Trauma 2008 Apr 64 (4)1010-23
bull Patients who have a significant injury present with a coagulopathy
bull Severity of injury and mortality is linearly associated with the degree of the initial coagulopathy
Coagulopathy
bull Although resuscitation strategies for severely injured patients who present WITH SHOCK have improved greatly the transfusions are associated with development of MOF and increased intensive care unit (ICU) admissions ICU and hospital length of stay and mortality
bull Malone DL Dunne J Tracy JK Putnam AT Scalea TM Napolitano LM Blood
transfusion independent of shock severity is associated with worse outcome in trauma J Trauma 2003 54898-905
bull Eastridge BJ Malone D Holcomb JB Early predictors of transfusion and mortality
after injury a review of the data-based literature J Trauma 2006 60S20-S25 bull Napolitano L Cumulative risks of early red blood cell transfusion J Trauma 2006
60S26-S34 bull Cotton BA Guy JS Morris JA Jr Abumrad NN The cellular metabolic and systemic
consequences of aggressive fluid resuscitation strategies Shock 2006 26115-121
Current transfusion practices and survival rates of massive transfusion patients vary widely among trauma centers Conventional guidelines may underestimate the optimal plasma and platelet to RBC ratios
Survival in patients is associated with increased plasma and platelet ratios Massive transfusion practice guidelines should aim for a111 ratio of plasma plateletsRBCs bullHolcomb et al Ann Surg 2008248447
Kaplan-Meier survival plot for the first 24 hours after admission for the 4 groups (high plasma (FFPH) or platelet (PltH) to RBC ratio 12 low plasma (FFPL) or platelet (PltL) to RBC ratio 12)
Statistical modeling indicated that a
clinical guideline with mean plasma
RBC ratio equal to 11 would
encompass 98 of patients within
the optimal 12 ratio
Hypotension A systolic blood pressure of 90 mm Hg or less is indicative casualties that have lost over 40 of their blood volume
(~2000 ml in an adult)
They have impending cardiovascular collapse and have significantly increased mortality
The most efficient solution for use in resuscitation is still under debate
Lactated Ringers (LR) and normal isotonic saline solution (NS) remain the
most commonly used isotonic fluids
Although colloid solutions including hyperosmolar colloid and hypertonic
electrolyte compounds have been approved for use as volume expanders
their administration is still under debate in the USA and Europe
Moore FA McKinley BA Moore EE Nathens AB West M Shapiro MB Bankey P Freeman B Harbrecht BG Johnson JL Minei JP Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core standard operating procedures for clinical care III Guidelines for shock resuscitation J Trauma 2006 6182-89 Spahn DR Cerny V Coats TJ Duranteau J Fernandez-Mondejar E Gordini G Stahel PF Hunt BJ Komadina R Neugebauer E Ozier Y Riddez L Schultz A Vincent JL Rossaint R Task Force for Advanced Bleeding Care in Trauma Management of bleeding following major trauma a European guideline Crit Care 2007 11R17
Experimental studies have revealed that resuscitation with NS in the setting of massive hemorrhage requires significantly greater volume and is associated with increased physiologic derangements (for example hyperchloremic acidosis and dilutional coagulopathy) and higher mortality as compared with LR Healey MA Davis RE Liu FC Loomis WH Hoyt DB Lactated ringers is superior to normal saline in a model of massive hemorrhage and resuscitation J Trauma 1998 45894-899 Todd SR Malinoski D Muller PJ Schreiber MA Lactated Ringers is superior to normal saline in the resuscitation of uncontrolled hemorrhagic shock J Trauma 2007 62636-639
Reported data from several studies conducted in critically ill patients have indicated that use of colloid solutions has a significant impact on hemorrhage hemostasis and inflammatory response Roberts I Alderson P Bunn F Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2004 CD000567 Vercueil A Grocott MP Mythen MG Physiology pharmacology and rationale for colloid administration for the maintenance of effective hemodynamic stability in critically ill patients Transfus Med Rev 2005 1993-109 Lee CC Chang IJ Yen ZS Effect of different resuscitation fluids on cytokine response in a rat model of hemorrhagic shock Shock 2005 24177-181
Early administration of blood is one potential treatment to decrease the
need for massive crystalloid solution in hemorrhagic shock however the
limited supply of stored blood and potential adverse effects make this
option logistically difficult and possibly harmful
West MA Sha piro MB Nathens AB Johnson JL Moore EE Minei JP Bankey PE Freeman B Harbrecht BG McKinley BA Moore FA Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core-standard operating procedures for clinical care IV Guidelines for transfusion in the trauma patient J Trauma 2006 61436-439
Moore FA McKinley BA Moore EE Nathens AB West M Shapiro MB Bankey P Freeman B Harbrecht BG Johnson JL Minei JP Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core standard operating procedures for clinical care III Guidelines for shock resuscitation J Trauma 2006 6182-89 Spahn DR Cerny V Coats TJ Duranteau J Fernandez-Mondejar E Gordini G Stahel PF Hunt BJ Komadina R Neugebauer E Ozier Y Riddez L Schultz A Vincent JL Rossaint R Task Force for Advanced Bleeding Care in Trauma Management of bleeding following major trauma a European guideline Crit Care 2007 11R17
Transfusion-related risks include possible development of MOF increased
ICU admissions and length of stay increased hospital length of stay and
mortality
Malone DL Dunne J Tracy JK Putnam AT Scalea TM Napolitano LM Blood transfusion independent of shock severity is associated with worse outcome in trauma J Trauma 2003 54898-905
Eastridge BJ Malone D Holcomb JB Early predictors of transfusion and mortality after injury a review of the data-based literature J Trauma 2006 60S20-S25
Napolitano L Cumulative risks of early red blood cell transfusion J Trauma 2006 60S26-S34
Cotton BA Guy JS Morris JA Jr Abumrad NN The cellular metabolic and systemic consequences of aggressive fluid resuscitation strategies Shock 2006 26115-121
uarr hemorrhage + excessive hemodilution due to
uarr Blood Presion darr blood viscosity darr hematocrit
darr clotting factor concentration
Risks of Aggressive Volume Resuscitation
rFVIIaThe use of rFVIIa was associated with improved early and late survival after severe trauma and massive transfusion
rFVIIa was not associated with increased risk of thrombotic events
The Effect of Recombinant Activated Factor VII on Mortality in Combat-Related Casualties With Severe Trauma and Massive Transfusion
bull Philip C Spinella MD Jeremy G Perkins MD Daniel F McLaughlin MD Sarah E Niles MD MPHKurt W Grathwohl MD Alec C Beekley MD Jose Salinas PhD Sumeru Mehta MD Charles E Wade PhDand John B Holcomb MD J of Trauma- Feb 2008bull Dutton et al J Trauma 200457709 Conclusion consider early use of FVIIa in any pt with uncontrolled hemorrhage who has not responded to surgery or blood component therapy
bull Each unit of blood product biologically active + elevates risk of infections + ARDS (SDRA)Chaiwat et al Anesthesiology 2009110351 n=14070 pts NSCOT database retrospective
bull Older blood association whith elevates infection LOS MOSF + death Weinberg et al J Trauma 200865279
TemperatureA temperature lt 96degF or 35degC is associated with an increase in mortality (cardiac arrest SRP higher abnormal plaquelet function) Burch J Denton J Noble R Physiologic rationale for abbreviated laparotomy Surg Clin North Am 1997 77779-82 Trauma patients that are hypothermic are NOT PERFUSING their tissue
The COAGULATION CASCADE is an enzymatic pathway that degrades with temperature and ceases at 92 FGregory JS Francbeum L Towsened MC Incidence and timing of hypothermia in trauma patients undergoing operations J Trauma 1991 31795-800 If the temperature is lower than 33 C the mortality is 100although Beilman and col think itacutes a significant factor for MODS but not for the mortalityBeilman GJ Blondet JJ Early hypothermia in severely injured trauma patients is a significant risk factor for multiple organ dysfunction syndrome but not mortality Ann Surg 2009 May249(5)845-50
Diagnosis done
Damage Control Resuscitation
1 Hypotensive resuscitation
2 Hemostatic resuscitation
Damage control philosophy can be extended to haemostatic resuscitation
Restoring normal coagulation Minimizing crystalloidTraditional resuscitation strategies dilute the already deficient coagulation factors and increase multiple organ failure
The aggressive hemostatic resuscitation should be combined with equally aggressive control of bleeding
Spahn DR Cerny V Management of bleeding following major trauma a European guidelineCrit Care 2007 11(1) R 17
WAIT AND SEE
SURGEON
ABDOMINAL PACKING is a lifesaving technique for temporary control of severe injury and it is used in damage control surgery schedule
Its possible too applying packs in organ-specific techniques (early abdominal packing)
The median survival of the 70 certainly superior to the obtainable survival with immediate surgical repairbullIMMEDIATE FAILURES are substantially due to bleeding especially in underpacking caseREMOTE FAILURES septic and bound at the time of stay (above the 72 hours) and associated by the coexistence of lesions in these situations is possible a MOF syndrome due to excessive intra-abdominal pressure (overpacking) or to an Abdominal Compartment Syndrome
Stagnitti F Bresadola L Calderale SM Coletti M Ribaldi S Salvi PF Schillaci F Abdominal packing indications and method Ann Ital Chir 2003 Sep-Oct74(5)535-42
Benavides C Garciacutea C Apablaza S Rubilar P Ricaurte F Perales C et al Empaquetamiento hepaacutetico permanente con malla de poliglactina en estallido hepaacutetico secundario a Siacutendrome de Hellp Rev Chil Cir 2004 56 275-278 De la Fuente M Mendoza VH Robledo-Oyarzun F Cierre Temporal de la pared abdominal con polietileno Cir Ciruj 2002 70157-63 Serna VH El Siacutendrome Compartamental Abdominal Tesis de Postgrado Meacutexico 2000
When skin approximation is
not possible a temporary silo
is constructed by suturing a 3-
L cystoscopy irrigation bag
(BOGOTAacute BAG) to the skin
edge with a continuous No 2
nylon suture
The method of closure depends on whether skin approximation produces excessive intra-abdominal hypertension
Towel-clip closure of the skin is preferred because it is quick and easy
The second phase is intra-operative reassessment for hemorrhage control 30 minutes after initial abdominal closure in the operating room focusing on restoration of the patients physiological status specifically reversing hypothermia and coagulopathy
WE CAN HEAR THE HEMORRHAGE
The abdomen is then reopened and assessed for adequacy of hemostasis and for existence of residual mechanical bleeding This practice has allowed surgeons to minimize both early return to the operating room for ongoing hemorrhage and the amount of packing necessary for hemostasis With bleeding effectively controlled the abdomen is reclosed
The patient is transferred to the ICU for continued physiologic restoration in the third phase
Once coagulopathy hypothermia and acidosis have been corrected the patient can be returned to the operating room for definitive management of the injuries in the fourth phase
48-72 h after first surgery
COMPLICATIONS OF DAMAGE CONTROL LAPAROTOMY
1) ACS Acute Compartmental Syndrome
2) ARDS Acute Respiratory Distress of the Adult
3) MOF Multiple organ failure
4) DEATH
ABDOMINAL COMPARTMENT SYNDROME is defined as an intra-abdominal pressure of greater than 20 cm H2O with evidence of impaired organ function ie elevated peak airway pressures (gt45 cm
H2O) oliguria (lt05 mLkg per hour) or cardiovascular dysfunction
(hypotension despite adequate volume resuscitation or if a pulmonary artery catheter is present oxygen delivery index [calculated as milliliters of oxygen per minute per meter squared] of 600) Intra-abdominal pressure was measured indirectly using an indwelling Foley catheter as previously described
Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13 Damage control surgery in the abdomen an approach for the management of severe injured patientsGermanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis NNuffield Department of Surgery John Radcliffe Hospital Oxford UK Curr Opin Crit Care 2006 Aug12(4)346-50 Damage-control laparotomy Lee JC Peitzman AB Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA
ABDOMINAL COMPARTMENT SYNDROME occurred in 17 (33) of
52 Patients undergoing damage-control laparotomy and was
associated with a much higher incidence of ARDS and MOF (71 vs
31 without ACS P = 02)
More importantly our study suggests that primary fascial closure at
the termination of the initial damage-control laparotomy contributes to
the development of ACS as well as subsequent organ failure
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal ypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
Mayberry JC Mullins RJ Crass RA Trunkey DD Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure Arch Surg 1997132957-962
bull MOF Multiple organ failure
Seems to be a major source of postinjury morbidity and the leading cause of in-hospital mortality despite more than 25 years of intense investigation
Eiseman B Beart R Norton L Multiple organ failure Surg Gynecol Obstet 1977144323-326
Bauer AE Durham R Faist E Systemic inflammatory response syndrome (SIRS) multiple organ dysfunction syndrome (MODS) multiple organ failure (MOF) are we winning the battle Shock 19981079-89
The current pathophysiologic model of MOF focuses on uncontrolled systemic
hyperinflammation as a unifying concept following a variety of insults
Moore FA Moore EE Evolving concepts in the pathogenesis of postinjury multiple organ failure Surg Clin North Am 199575257-277
Goris RJ te Boekhorst TP Nuytinck JK Gimbrere JS Multiple-organ failure generalized autodestructive inflammation Arch Surg 19851201109-1115
Nuytinck HK Offermans XJ Kubat K Goris JA Whole-body inflammation in trauma patients an autopsy study Arch Surg 19881231519-1524
Examples that improve the prognosis of MOF include damage control surgery recognition of abdominal compartment syndrome lung protective ventilation
strategies and tight glucose level control
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal hypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
The Acute Respiratory Distress Syndrome Network Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome N Engl J Med 20003421301-1308
Amato MB Barbas CS Medeiros DM et al Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome N Engl J Med 1998338347-354
Van den Berghe G Wouters P Weekers F et al Intensive insulin therapy in the critically ill patients N Engl J Med 20013451359-1367
The incidence of postinjury MOF has been reported to be between 7 and 66 with an associated mortality rate between 31 and 80
Fry DE Pearlstein L Fulton RL Polk HC Jr Multiple system organ failure the role of uncontrolled infection Arch Surg 1980115136-140
Regel G Lobenhoffer P Grotz M Pape HC Lehmann U Tscherne H Treatment results of patients with multiple trauma an analysis of 3406 cases treated between 1972 and 1991 at a German level I trauma center J Trauma 19953870-78
Sauaia A Moore FA Moore EE Norris JM Lezotte DC Hamman RF Multiple organ failure can be predicted as early as 12 hours after injury J Trauma 199845291-303
Nast-Kolb D Aufmkolk M Rucholtz S Obertacke U Waydhas C Multiple organ failure still a major cause of morbidity but not mortality in blunt multiple trauma J Trauma 200151835-842 Durham RM Moran JJ Mazuski JE Shapiro MJ Baue AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
It has been suggested that MOF is disappearing owing to advances in trauma and critical care
Levine JH Durham RM Moran J Bauer A Multiple organ failure is it disappearing World J Surg 199620471-473
Recent reports have not demonstrated a consistent change in either the incidence or the mortality rate associated with postinjury MOF Some groups have reported no change in the incidence but a decreased mortality while others have reported both decreased incidence and mortality compared with historical control subjects
Durham RM Moran JJ Mazuski JE Shapiro MJ Bauer AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
Regel G Grotz M Weltner T Sturm JA Tscherne H Pattern of organ failure following severe trauma World J Surg 199620422-429
Orthopaedic Trauma
Open pelvic fractures in addition to the pelvic ring injury are associated with hemorrhage and neurological insult visceral injuries are more common and a high rate of infection is seen Mortality of open pelvic fractures historically approached 50 Control of bleeding is the most important initial measure followed by debridement and packing of open wounds
Open book- widened symphysis pubis Dislocated Rt SI joint Vallier + Jenkins In Trauma Anesthesia 2008
Type 1 fractures occur due to anterior-posterior
compressioncan cause the symphysis pubis to ldquopoprdquo open leading to pubic rami or ldquoopen
bookrdquo fractures A lateral compression fracture type 2 or vertical sheer facture (Type 3) can
also lead to severe bleeding Into the pelvis Pelvic and acetabular surgery are major surgical interventions
Figura 1- Aplicacioacuten de la engrapadora para la reseccioacuten pulmonar en cuntildea Los segmentos a resecar se limitan por medio de la aplicacioacuten de dispositivos de grapado orientados en direcciones perpendiculares tratando de mantener la mayor cantidad de tejido sano
Insercioacuten de engrapadora lineal cortante a traveacutes de los orificios del tracto de la herida pulmonar penetrante
Figura 3- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales con fuga aeacuterea visible
Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales
Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
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-
bull 1) HISTORICAL NOTES
bull 2) CURRENT CONCEPTS
bull 3) SO NOW WHAT
SHOCK is a state of compromised tissue perfusion that causes cellular hypoxia
It is a syndrome initiated by ACUTE HYPOPERFUSION leading to tissue hypoxia and vital organ dysfunction
Shock is a SYSTEMIC DISORDER affecting MULTIPLE ORGAN SYSTEMS
During shock PERFUSION IS INSUFFICIENT to meet the metabolic demands of the tissues
CELLULAR HYPOXIA and end ORGAN DAMAGE
Principle of Medicine
PRIMUM NON NOCEREldquoFirst do no harmrdquo
Hippocrates
ldquoDamage Control Resuscitation represents the most important advance in trauma care for hospitalized civilian and military casualties from this warrdquo
Cordts Brosch and Holcomb J Trauma 2008
His surgical technical was modified by HALSTED in 1913Garciacutea-Nuacutentildeez L Cabello R Lever C Rosales E Padilla R Garduntildeo P et alConceptos Actuales en Cirugiacutea Abdominal de Control de DantildeosComunicacioacuten acerca de donde hacer menos es hacer maacutes Trauma 2005 8 76-81
The abdominal packing has been the basement for the damage control surgery and the first phisician (military surgeon) who reported was PRINGLE in 1908
Pringle JH Notes on the arrest of hepatic hemorrhage due to trauma Ann Surg 1908 48541-9
bull In 1955 MADDING studied the temporal packing in hemorragic control after abdominal surgery
bull The MODERN era of damage-control laparotomy began with the seminal report of STONE ET AL from the Grady Memorial Hospital Atlanta Ga in 1982
Stone H Strom P Mullines R Management of the major coagulopathy with on set during laparotomy Ann Surg 1983 197532-535
bull The concept of damage control was introduced by ROTONDO y SCHWAB in patients with dangerous abdominal trauma described the three times in this surgery
Rotondo MF Mc Gonigol MD Schwab CW Kauder DR Hanson CW Damage Control An approach for improved survival in exsanguinating penetrating abdominal injury J Trauma 1993 35375-83
New Diagnostic criteriaAvoids the ldquobut he looked goodrdquo phenomenon
Within the first five minutes in the ED
Identify patients in trouble
Identify patients with increased mortality
Identify patients with increased probability of massive transfusion
The CONDUCT OF DAMAGE-CONTROL LAPAROTOMY has been described in detail elsewhere we can view the process in STAGES
Germanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis N Damage control surgery in the abdomen an approach for the management of severe injured patients Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13Lee JC Peitzman AB Nuffield Department of Surgery John Radcliffe Hospital Oxford UK Damage-control laparotomy Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA Curr Opin Crit Care 2006 Aug12(4)346-50
The MORE IMPORTANT PHASE is to IDENTIFY the appropriate candidate
bull Acidosis- Base Deficit gt - 6 phlt 72bull Coagulopathy INR gt 15 or TTPA gt 60 scbull Hypotension Systolic BP lt 90 mmHgbull Need of transfusion gt 4 l red cell contentsbull Temperature lt 96 5 F=34 Cbull Pattern recognition
bull Weak or absent radial pulse bull Abnormal mental statusbull Severe Traumatic Injury
DEATH
HYPOTHERMIA
ACIDOSIS
COAGULOPATHY
The Lethal TriadThe Lethal TriadThe Lethal TriadThe Lethal Triad
Soto S Oettinger R Brousse J Saacutenchez G Cirugiacutea de Control de Dantildeos Enfrentamiento actual del Trauma Cuad Cir 20031795-102
The OBJECTIVES are
1) STOP HEMORRHAGE to correct underlying coagulopathy
2) MINIMIZE PERITONEAL CONTAMINATION and its secondary inflammatory response
3) ENCLOSE THE ABDOMINAL CONTENTS to protect viscera and minimize protein loss
4) The final objective of this damage-control phase is CLOSURE OF THE ABDOMINAL CAVITY
bullRequires robust MEDICAL SETTING
bullNeed system approach to deliver casualties to MOST CAPABLE FACILITIES
bullIsolated and far forward facilities can still benefit from these principles
AcidosisAcidosisBASE DEFICIT (BD) ge -15 identifies patients that require early
transfusion increased ICU days and risk for ARDS and MOF Ferrara A Mac Arthur J Wright H Hypothermia and Acidosis worsen coagulopathy in the patient requiring massive transfusion Ann J Surg 1990 160515-518
bull BD of ge -15 is strongly associated with the need for massive transfusion and mortality in patients
Rutherford EJ Morris JA Reed GW Hall KS Base deficit stratifies mortality and determines therapy J Trauma 1992 33417-23
bull Patients have an elevated BD before their blood pressure drops to classic ldquohypotensionrdquo levels
bull Acidosis contributes more to coagulopathy more than hypothermia (not reversible)
bull An initial INR ge 15 reliably predicts those who will require massive transfusion
Moore FA Nelson T Massive transfusion in trauma patients tissue hemoglobin oxygen saturation predicts poor outcom J Trauma 2008 Apr 64 (4)1010-23
bull Patients who have a significant injury present with a coagulopathy
bull Severity of injury and mortality is linearly associated with the degree of the initial coagulopathy
Coagulopathy
bull Although resuscitation strategies for severely injured patients who present WITH SHOCK have improved greatly the transfusions are associated with development of MOF and increased intensive care unit (ICU) admissions ICU and hospital length of stay and mortality
bull Malone DL Dunne J Tracy JK Putnam AT Scalea TM Napolitano LM Blood
transfusion independent of shock severity is associated with worse outcome in trauma J Trauma 2003 54898-905
bull Eastridge BJ Malone D Holcomb JB Early predictors of transfusion and mortality
after injury a review of the data-based literature J Trauma 2006 60S20-S25 bull Napolitano L Cumulative risks of early red blood cell transfusion J Trauma 2006
60S26-S34 bull Cotton BA Guy JS Morris JA Jr Abumrad NN The cellular metabolic and systemic
consequences of aggressive fluid resuscitation strategies Shock 2006 26115-121
Current transfusion practices and survival rates of massive transfusion patients vary widely among trauma centers Conventional guidelines may underestimate the optimal plasma and platelet to RBC ratios
Survival in patients is associated with increased plasma and platelet ratios Massive transfusion practice guidelines should aim for a111 ratio of plasma plateletsRBCs bullHolcomb et al Ann Surg 2008248447
Kaplan-Meier survival plot for the first 24 hours after admission for the 4 groups (high plasma (FFPH) or platelet (PltH) to RBC ratio 12 low plasma (FFPL) or platelet (PltL) to RBC ratio 12)
Statistical modeling indicated that a
clinical guideline with mean plasma
RBC ratio equal to 11 would
encompass 98 of patients within
the optimal 12 ratio
Hypotension A systolic blood pressure of 90 mm Hg or less is indicative casualties that have lost over 40 of their blood volume
(~2000 ml in an adult)
They have impending cardiovascular collapse and have significantly increased mortality
The most efficient solution for use in resuscitation is still under debate
Lactated Ringers (LR) and normal isotonic saline solution (NS) remain the
most commonly used isotonic fluids
Although colloid solutions including hyperosmolar colloid and hypertonic
electrolyte compounds have been approved for use as volume expanders
their administration is still under debate in the USA and Europe
Moore FA McKinley BA Moore EE Nathens AB West M Shapiro MB Bankey P Freeman B Harbrecht BG Johnson JL Minei JP Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core standard operating procedures for clinical care III Guidelines for shock resuscitation J Trauma 2006 6182-89 Spahn DR Cerny V Coats TJ Duranteau J Fernandez-Mondejar E Gordini G Stahel PF Hunt BJ Komadina R Neugebauer E Ozier Y Riddez L Schultz A Vincent JL Rossaint R Task Force for Advanced Bleeding Care in Trauma Management of bleeding following major trauma a European guideline Crit Care 2007 11R17
Experimental studies have revealed that resuscitation with NS in the setting of massive hemorrhage requires significantly greater volume and is associated with increased physiologic derangements (for example hyperchloremic acidosis and dilutional coagulopathy) and higher mortality as compared with LR Healey MA Davis RE Liu FC Loomis WH Hoyt DB Lactated ringers is superior to normal saline in a model of massive hemorrhage and resuscitation J Trauma 1998 45894-899 Todd SR Malinoski D Muller PJ Schreiber MA Lactated Ringers is superior to normal saline in the resuscitation of uncontrolled hemorrhagic shock J Trauma 2007 62636-639
Reported data from several studies conducted in critically ill patients have indicated that use of colloid solutions has a significant impact on hemorrhage hemostasis and inflammatory response Roberts I Alderson P Bunn F Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2004 CD000567 Vercueil A Grocott MP Mythen MG Physiology pharmacology and rationale for colloid administration for the maintenance of effective hemodynamic stability in critically ill patients Transfus Med Rev 2005 1993-109 Lee CC Chang IJ Yen ZS Effect of different resuscitation fluids on cytokine response in a rat model of hemorrhagic shock Shock 2005 24177-181
Early administration of blood is one potential treatment to decrease the
need for massive crystalloid solution in hemorrhagic shock however the
limited supply of stored blood and potential adverse effects make this
option logistically difficult and possibly harmful
West MA Sha piro MB Nathens AB Johnson JL Moore EE Minei JP Bankey PE Freeman B Harbrecht BG McKinley BA Moore FA Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core-standard operating procedures for clinical care IV Guidelines for transfusion in the trauma patient J Trauma 2006 61436-439
Moore FA McKinley BA Moore EE Nathens AB West M Shapiro MB Bankey P Freeman B Harbrecht BG Johnson JL Minei JP Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core standard operating procedures for clinical care III Guidelines for shock resuscitation J Trauma 2006 6182-89 Spahn DR Cerny V Coats TJ Duranteau J Fernandez-Mondejar E Gordini G Stahel PF Hunt BJ Komadina R Neugebauer E Ozier Y Riddez L Schultz A Vincent JL Rossaint R Task Force for Advanced Bleeding Care in Trauma Management of bleeding following major trauma a European guideline Crit Care 2007 11R17
Transfusion-related risks include possible development of MOF increased
ICU admissions and length of stay increased hospital length of stay and
mortality
Malone DL Dunne J Tracy JK Putnam AT Scalea TM Napolitano LM Blood transfusion independent of shock severity is associated with worse outcome in trauma J Trauma 2003 54898-905
Eastridge BJ Malone D Holcomb JB Early predictors of transfusion and mortality after injury a review of the data-based literature J Trauma 2006 60S20-S25
Napolitano L Cumulative risks of early red blood cell transfusion J Trauma 2006 60S26-S34
Cotton BA Guy JS Morris JA Jr Abumrad NN The cellular metabolic and systemic consequences of aggressive fluid resuscitation strategies Shock 2006 26115-121
uarr hemorrhage + excessive hemodilution due to
uarr Blood Presion darr blood viscosity darr hematocrit
darr clotting factor concentration
Risks of Aggressive Volume Resuscitation
rFVIIaThe use of rFVIIa was associated with improved early and late survival after severe trauma and massive transfusion
rFVIIa was not associated with increased risk of thrombotic events
The Effect of Recombinant Activated Factor VII on Mortality in Combat-Related Casualties With Severe Trauma and Massive Transfusion
bull Philip C Spinella MD Jeremy G Perkins MD Daniel F McLaughlin MD Sarah E Niles MD MPHKurt W Grathwohl MD Alec C Beekley MD Jose Salinas PhD Sumeru Mehta MD Charles E Wade PhDand John B Holcomb MD J of Trauma- Feb 2008bull Dutton et al J Trauma 200457709 Conclusion consider early use of FVIIa in any pt with uncontrolled hemorrhage who has not responded to surgery or blood component therapy
bull Each unit of blood product biologically active + elevates risk of infections + ARDS (SDRA)Chaiwat et al Anesthesiology 2009110351 n=14070 pts NSCOT database retrospective
bull Older blood association whith elevates infection LOS MOSF + death Weinberg et al J Trauma 200865279
TemperatureA temperature lt 96degF or 35degC is associated with an increase in mortality (cardiac arrest SRP higher abnormal plaquelet function) Burch J Denton J Noble R Physiologic rationale for abbreviated laparotomy Surg Clin North Am 1997 77779-82 Trauma patients that are hypothermic are NOT PERFUSING their tissue
The COAGULATION CASCADE is an enzymatic pathway that degrades with temperature and ceases at 92 FGregory JS Francbeum L Towsened MC Incidence and timing of hypothermia in trauma patients undergoing operations J Trauma 1991 31795-800 If the temperature is lower than 33 C the mortality is 100although Beilman and col think itacutes a significant factor for MODS but not for the mortalityBeilman GJ Blondet JJ Early hypothermia in severely injured trauma patients is a significant risk factor for multiple organ dysfunction syndrome but not mortality Ann Surg 2009 May249(5)845-50
Diagnosis done
Damage Control Resuscitation
1 Hypotensive resuscitation
2 Hemostatic resuscitation
Damage control philosophy can be extended to haemostatic resuscitation
Restoring normal coagulation Minimizing crystalloidTraditional resuscitation strategies dilute the already deficient coagulation factors and increase multiple organ failure
The aggressive hemostatic resuscitation should be combined with equally aggressive control of bleeding
Spahn DR Cerny V Management of bleeding following major trauma a European guidelineCrit Care 2007 11(1) R 17
WAIT AND SEE
SURGEON
ABDOMINAL PACKING is a lifesaving technique for temporary control of severe injury and it is used in damage control surgery schedule
Its possible too applying packs in organ-specific techniques (early abdominal packing)
The median survival of the 70 certainly superior to the obtainable survival with immediate surgical repairbullIMMEDIATE FAILURES are substantially due to bleeding especially in underpacking caseREMOTE FAILURES septic and bound at the time of stay (above the 72 hours) and associated by the coexistence of lesions in these situations is possible a MOF syndrome due to excessive intra-abdominal pressure (overpacking) or to an Abdominal Compartment Syndrome
Stagnitti F Bresadola L Calderale SM Coletti M Ribaldi S Salvi PF Schillaci F Abdominal packing indications and method Ann Ital Chir 2003 Sep-Oct74(5)535-42
Benavides C Garciacutea C Apablaza S Rubilar P Ricaurte F Perales C et al Empaquetamiento hepaacutetico permanente con malla de poliglactina en estallido hepaacutetico secundario a Siacutendrome de Hellp Rev Chil Cir 2004 56 275-278 De la Fuente M Mendoza VH Robledo-Oyarzun F Cierre Temporal de la pared abdominal con polietileno Cir Ciruj 2002 70157-63 Serna VH El Siacutendrome Compartamental Abdominal Tesis de Postgrado Meacutexico 2000
When skin approximation is
not possible a temporary silo
is constructed by suturing a 3-
L cystoscopy irrigation bag
(BOGOTAacute BAG) to the skin
edge with a continuous No 2
nylon suture
The method of closure depends on whether skin approximation produces excessive intra-abdominal hypertension
Towel-clip closure of the skin is preferred because it is quick and easy
The second phase is intra-operative reassessment for hemorrhage control 30 minutes after initial abdominal closure in the operating room focusing on restoration of the patients physiological status specifically reversing hypothermia and coagulopathy
WE CAN HEAR THE HEMORRHAGE
The abdomen is then reopened and assessed for adequacy of hemostasis and for existence of residual mechanical bleeding This practice has allowed surgeons to minimize both early return to the operating room for ongoing hemorrhage and the amount of packing necessary for hemostasis With bleeding effectively controlled the abdomen is reclosed
The patient is transferred to the ICU for continued physiologic restoration in the third phase
Once coagulopathy hypothermia and acidosis have been corrected the patient can be returned to the operating room for definitive management of the injuries in the fourth phase
48-72 h after first surgery
COMPLICATIONS OF DAMAGE CONTROL LAPAROTOMY
1) ACS Acute Compartmental Syndrome
2) ARDS Acute Respiratory Distress of the Adult
3) MOF Multiple organ failure
4) DEATH
ABDOMINAL COMPARTMENT SYNDROME is defined as an intra-abdominal pressure of greater than 20 cm H2O with evidence of impaired organ function ie elevated peak airway pressures (gt45 cm
H2O) oliguria (lt05 mLkg per hour) or cardiovascular dysfunction
(hypotension despite adequate volume resuscitation or if a pulmonary artery catheter is present oxygen delivery index [calculated as milliliters of oxygen per minute per meter squared] of 600) Intra-abdominal pressure was measured indirectly using an indwelling Foley catheter as previously described
Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13 Damage control surgery in the abdomen an approach for the management of severe injured patientsGermanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis NNuffield Department of Surgery John Radcliffe Hospital Oxford UK Curr Opin Crit Care 2006 Aug12(4)346-50 Damage-control laparotomy Lee JC Peitzman AB Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA
ABDOMINAL COMPARTMENT SYNDROME occurred in 17 (33) of
52 Patients undergoing damage-control laparotomy and was
associated with a much higher incidence of ARDS and MOF (71 vs
31 without ACS P = 02)
More importantly our study suggests that primary fascial closure at
the termination of the initial damage-control laparotomy contributes to
the development of ACS as well as subsequent organ failure
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal ypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
Mayberry JC Mullins RJ Crass RA Trunkey DD Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure Arch Surg 1997132957-962
bull MOF Multiple organ failure
Seems to be a major source of postinjury morbidity and the leading cause of in-hospital mortality despite more than 25 years of intense investigation
Eiseman B Beart R Norton L Multiple organ failure Surg Gynecol Obstet 1977144323-326
Bauer AE Durham R Faist E Systemic inflammatory response syndrome (SIRS) multiple organ dysfunction syndrome (MODS) multiple organ failure (MOF) are we winning the battle Shock 19981079-89
The current pathophysiologic model of MOF focuses on uncontrolled systemic
hyperinflammation as a unifying concept following a variety of insults
Moore FA Moore EE Evolving concepts in the pathogenesis of postinjury multiple organ failure Surg Clin North Am 199575257-277
Goris RJ te Boekhorst TP Nuytinck JK Gimbrere JS Multiple-organ failure generalized autodestructive inflammation Arch Surg 19851201109-1115
Nuytinck HK Offermans XJ Kubat K Goris JA Whole-body inflammation in trauma patients an autopsy study Arch Surg 19881231519-1524
Examples that improve the prognosis of MOF include damage control surgery recognition of abdominal compartment syndrome lung protective ventilation
strategies and tight glucose level control
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal hypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
The Acute Respiratory Distress Syndrome Network Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome N Engl J Med 20003421301-1308
Amato MB Barbas CS Medeiros DM et al Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome N Engl J Med 1998338347-354
Van den Berghe G Wouters P Weekers F et al Intensive insulin therapy in the critically ill patients N Engl J Med 20013451359-1367
The incidence of postinjury MOF has been reported to be between 7 and 66 with an associated mortality rate between 31 and 80
Fry DE Pearlstein L Fulton RL Polk HC Jr Multiple system organ failure the role of uncontrolled infection Arch Surg 1980115136-140
Regel G Lobenhoffer P Grotz M Pape HC Lehmann U Tscherne H Treatment results of patients with multiple trauma an analysis of 3406 cases treated between 1972 and 1991 at a German level I trauma center J Trauma 19953870-78
Sauaia A Moore FA Moore EE Norris JM Lezotte DC Hamman RF Multiple organ failure can be predicted as early as 12 hours after injury J Trauma 199845291-303
Nast-Kolb D Aufmkolk M Rucholtz S Obertacke U Waydhas C Multiple organ failure still a major cause of morbidity but not mortality in blunt multiple trauma J Trauma 200151835-842 Durham RM Moran JJ Mazuski JE Shapiro MJ Baue AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
It has been suggested that MOF is disappearing owing to advances in trauma and critical care
Levine JH Durham RM Moran J Bauer A Multiple organ failure is it disappearing World J Surg 199620471-473
Recent reports have not demonstrated a consistent change in either the incidence or the mortality rate associated with postinjury MOF Some groups have reported no change in the incidence but a decreased mortality while others have reported both decreased incidence and mortality compared with historical control subjects
Durham RM Moran JJ Mazuski JE Shapiro MJ Bauer AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
Regel G Grotz M Weltner T Sturm JA Tscherne H Pattern of organ failure following severe trauma World J Surg 199620422-429
Orthopaedic Trauma
Open pelvic fractures in addition to the pelvic ring injury are associated with hemorrhage and neurological insult visceral injuries are more common and a high rate of infection is seen Mortality of open pelvic fractures historically approached 50 Control of bleeding is the most important initial measure followed by debridement and packing of open wounds
Open book- widened symphysis pubis Dislocated Rt SI joint Vallier + Jenkins In Trauma Anesthesia 2008
Type 1 fractures occur due to anterior-posterior
compressioncan cause the symphysis pubis to ldquopoprdquo open leading to pubic rami or ldquoopen
bookrdquo fractures A lateral compression fracture type 2 or vertical sheer facture (Type 3) can
also lead to severe bleeding Into the pelvis Pelvic and acetabular surgery are major surgical interventions
Figura 1- Aplicacioacuten de la engrapadora para la reseccioacuten pulmonar en cuntildea Los segmentos a resecar se limitan por medio de la aplicacioacuten de dispositivos de grapado orientados en direcciones perpendiculares tratando de mantener la mayor cantidad de tejido sano
Insercioacuten de engrapadora lineal cortante a traveacutes de los orificios del tracto de la herida pulmonar penetrante
Figura 3- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales con fuga aeacuterea visible
Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales
Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
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-
SHOCK is a state of compromised tissue perfusion that causes cellular hypoxia
It is a syndrome initiated by ACUTE HYPOPERFUSION leading to tissue hypoxia and vital organ dysfunction
Shock is a SYSTEMIC DISORDER affecting MULTIPLE ORGAN SYSTEMS
During shock PERFUSION IS INSUFFICIENT to meet the metabolic demands of the tissues
CELLULAR HYPOXIA and end ORGAN DAMAGE
Principle of Medicine
PRIMUM NON NOCEREldquoFirst do no harmrdquo
Hippocrates
ldquoDamage Control Resuscitation represents the most important advance in trauma care for hospitalized civilian and military casualties from this warrdquo
Cordts Brosch and Holcomb J Trauma 2008
His surgical technical was modified by HALSTED in 1913Garciacutea-Nuacutentildeez L Cabello R Lever C Rosales E Padilla R Garduntildeo P et alConceptos Actuales en Cirugiacutea Abdominal de Control de DantildeosComunicacioacuten acerca de donde hacer menos es hacer maacutes Trauma 2005 8 76-81
The abdominal packing has been the basement for the damage control surgery and the first phisician (military surgeon) who reported was PRINGLE in 1908
Pringle JH Notes on the arrest of hepatic hemorrhage due to trauma Ann Surg 1908 48541-9
bull In 1955 MADDING studied the temporal packing in hemorragic control after abdominal surgery
bull The MODERN era of damage-control laparotomy began with the seminal report of STONE ET AL from the Grady Memorial Hospital Atlanta Ga in 1982
Stone H Strom P Mullines R Management of the major coagulopathy with on set during laparotomy Ann Surg 1983 197532-535
bull The concept of damage control was introduced by ROTONDO y SCHWAB in patients with dangerous abdominal trauma described the three times in this surgery
Rotondo MF Mc Gonigol MD Schwab CW Kauder DR Hanson CW Damage Control An approach for improved survival in exsanguinating penetrating abdominal injury J Trauma 1993 35375-83
New Diagnostic criteriaAvoids the ldquobut he looked goodrdquo phenomenon
Within the first five minutes in the ED
Identify patients in trouble
Identify patients with increased mortality
Identify patients with increased probability of massive transfusion
The CONDUCT OF DAMAGE-CONTROL LAPAROTOMY has been described in detail elsewhere we can view the process in STAGES
Germanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis N Damage control surgery in the abdomen an approach for the management of severe injured patients Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13Lee JC Peitzman AB Nuffield Department of Surgery John Radcliffe Hospital Oxford UK Damage-control laparotomy Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA Curr Opin Crit Care 2006 Aug12(4)346-50
The MORE IMPORTANT PHASE is to IDENTIFY the appropriate candidate
bull Acidosis- Base Deficit gt - 6 phlt 72bull Coagulopathy INR gt 15 or TTPA gt 60 scbull Hypotension Systolic BP lt 90 mmHgbull Need of transfusion gt 4 l red cell contentsbull Temperature lt 96 5 F=34 Cbull Pattern recognition
bull Weak or absent radial pulse bull Abnormal mental statusbull Severe Traumatic Injury
DEATH
HYPOTHERMIA
ACIDOSIS
COAGULOPATHY
The Lethal TriadThe Lethal TriadThe Lethal TriadThe Lethal Triad
Soto S Oettinger R Brousse J Saacutenchez G Cirugiacutea de Control de Dantildeos Enfrentamiento actual del Trauma Cuad Cir 20031795-102
The OBJECTIVES are
1) STOP HEMORRHAGE to correct underlying coagulopathy
2) MINIMIZE PERITONEAL CONTAMINATION and its secondary inflammatory response
3) ENCLOSE THE ABDOMINAL CONTENTS to protect viscera and minimize protein loss
4) The final objective of this damage-control phase is CLOSURE OF THE ABDOMINAL CAVITY
bullRequires robust MEDICAL SETTING
bullNeed system approach to deliver casualties to MOST CAPABLE FACILITIES
bullIsolated and far forward facilities can still benefit from these principles
AcidosisAcidosisBASE DEFICIT (BD) ge -15 identifies patients that require early
transfusion increased ICU days and risk for ARDS and MOF Ferrara A Mac Arthur J Wright H Hypothermia and Acidosis worsen coagulopathy in the patient requiring massive transfusion Ann J Surg 1990 160515-518
bull BD of ge -15 is strongly associated with the need for massive transfusion and mortality in patients
Rutherford EJ Morris JA Reed GW Hall KS Base deficit stratifies mortality and determines therapy J Trauma 1992 33417-23
bull Patients have an elevated BD before their blood pressure drops to classic ldquohypotensionrdquo levels
bull Acidosis contributes more to coagulopathy more than hypothermia (not reversible)
bull An initial INR ge 15 reliably predicts those who will require massive transfusion
Moore FA Nelson T Massive transfusion in trauma patients tissue hemoglobin oxygen saturation predicts poor outcom J Trauma 2008 Apr 64 (4)1010-23
bull Patients who have a significant injury present with a coagulopathy
bull Severity of injury and mortality is linearly associated with the degree of the initial coagulopathy
Coagulopathy
bull Although resuscitation strategies for severely injured patients who present WITH SHOCK have improved greatly the transfusions are associated with development of MOF and increased intensive care unit (ICU) admissions ICU and hospital length of stay and mortality
bull Malone DL Dunne J Tracy JK Putnam AT Scalea TM Napolitano LM Blood
transfusion independent of shock severity is associated with worse outcome in trauma J Trauma 2003 54898-905
bull Eastridge BJ Malone D Holcomb JB Early predictors of transfusion and mortality
after injury a review of the data-based literature J Trauma 2006 60S20-S25 bull Napolitano L Cumulative risks of early red blood cell transfusion J Trauma 2006
60S26-S34 bull Cotton BA Guy JS Morris JA Jr Abumrad NN The cellular metabolic and systemic
consequences of aggressive fluid resuscitation strategies Shock 2006 26115-121
Current transfusion practices and survival rates of massive transfusion patients vary widely among trauma centers Conventional guidelines may underestimate the optimal plasma and platelet to RBC ratios
Survival in patients is associated with increased plasma and platelet ratios Massive transfusion practice guidelines should aim for a111 ratio of plasma plateletsRBCs bullHolcomb et al Ann Surg 2008248447
Kaplan-Meier survival plot for the first 24 hours after admission for the 4 groups (high plasma (FFPH) or platelet (PltH) to RBC ratio 12 low plasma (FFPL) or platelet (PltL) to RBC ratio 12)
Statistical modeling indicated that a
clinical guideline with mean plasma
RBC ratio equal to 11 would
encompass 98 of patients within
the optimal 12 ratio
Hypotension A systolic blood pressure of 90 mm Hg or less is indicative casualties that have lost over 40 of their blood volume
(~2000 ml in an adult)
They have impending cardiovascular collapse and have significantly increased mortality
The most efficient solution for use in resuscitation is still under debate
Lactated Ringers (LR) and normal isotonic saline solution (NS) remain the
most commonly used isotonic fluids
Although colloid solutions including hyperosmolar colloid and hypertonic
electrolyte compounds have been approved for use as volume expanders
their administration is still under debate in the USA and Europe
Moore FA McKinley BA Moore EE Nathens AB West M Shapiro MB Bankey P Freeman B Harbrecht BG Johnson JL Minei JP Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core standard operating procedures for clinical care III Guidelines for shock resuscitation J Trauma 2006 6182-89 Spahn DR Cerny V Coats TJ Duranteau J Fernandez-Mondejar E Gordini G Stahel PF Hunt BJ Komadina R Neugebauer E Ozier Y Riddez L Schultz A Vincent JL Rossaint R Task Force for Advanced Bleeding Care in Trauma Management of bleeding following major trauma a European guideline Crit Care 2007 11R17
Experimental studies have revealed that resuscitation with NS in the setting of massive hemorrhage requires significantly greater volume and is associated with increased physiologic derangements (for example hyperchloremic acidosis and dilutional coagulopathy) and higher mortality as compared with LR Healey MA Davis RE Liu FC Loomis WH Hoyt DB Lactated ringers is superior to normal saline in a model of massive hemorrhage and resuscitation J Trauma 1998 45894-899 Todd SR Malinoski D Muller PJ Schreiber MA Lactated Ringers is superior to normal saline in the resuscitation of uncontrolled hemorrhagic shock J Trauma 2007 62636-639
Reported data from several studies conducted in critically ill patients have indicated that use of colloid solutions has a significant impact on hemorrhage hemostasis and inflammatory response Roberts I Alderson P Bunn F Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2004 CD000567 Vercueil A Grocott MP Mythen MG Physiology pharmacology and rationale for colloid administration for the maintenance of effective hemodynamic stability in critically ill patients Transfus Med Rev 2005 1993-109 Lee CC Chang IJ Yen ZS Effect of different resuscitation fluids on cytokine response in a rat model of hemorrhagic shock Shock 2005 24177-181
Early administration of blood is one potential treatment to decrease the
need for massive crystalloid solution in hemorrhagic shock however the
limited supply of stored blood and potential adverse effects make this
option logistically difficult and possibly harmful
West MA Sha piro MB Nathens AB Johnson JL Moore EE Minei JP Bankey PE Freeman B Harbrecht BG McKinley BA Moore FA Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core-standard operating procedures for clinical care IV Guidelines for transfusion in the trauma patient J Trauma 2006 61436-439
Moore FA McKinley BA Moore EE Nathens AB West M Shapiro MB Bankey P Freeman B Harbrecht BG Johnson JL Minei JP Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core standard operating procedures for clinical care III Guidelines for shock resuscitation J Trauma 2006 6182-89 Spahn DR Cerny V Coats TJ Duranteau J Fernandez-Mondejar E Gordini G Stahel PF Hunt BJ Komadina R Neugebauer E Ozier Y Riddez L Schultz A Vincent JL Rossaint R Task Force for Advanced Bleeding Care in Trauma Management of bleeding following major trauma a European guideline Crit Care 2007 11R17
Transfusion-related risks include possible development of MOF increased
ICU admissions and length of stay increased hospital length of stay and
mortality
Malone DL Dunne J Tracy JK Putnam AT Scalea TM Napolitano LM Blood transfusion independent of shock severity is associated with worse outcome in trauma J Trauma 2003 54898-905
Eastridge BJ Malone D Holcomb JB Early predictors of transfusion and mortality after injury a review of the data-based literature J Trauma 2006 60S20-S25
Napolitano L Cumulative risks of early red blood cell transfusion J Trauma 2006 60S26-S34
Cotton BA Guy JS Morris JA Jr Abumrad NN The cellular metabolic and systemic consequences of aggressive fluid resuscitation strategies Shock 2006 26115-121
uarr hemorrhage + excessive hemodilution due to
uarr Blood Presion darr blood viscosity darr hematocrit
darr clotting factor concentration
Risks of Aggressive Volume Resuscitation
rFVIIaThe use of rFVIIa was associated with improved early and late survival after severe trauma and massive transfusion
rFVIIa was not associated with increased risk of thrombotic events
The Effect of Recombinant Activated Factor VII on Mortality in Combat-Related Casualties With Severe Trauma and Massive Transfusion
bull Philip C Spinella MD Jeremy G Perkins MD Daniel F McLaughlin MD Sarah E Niles MD MPHKurt W Grathwohl MD Alec C Beekley MD Jose Salinas PhD Sumeru Mehta MD Charles E Wade PhDand John B Holcomb MD J of Trauma- Feb 2008bull Dutton et al J Trauma 200457709 Conclusion consider early use of FVIIa in any pt with uncontrolled hemorrhage who has not responded to surgery or blood component therapy
bull Each unit of blood product biologically active + elevates risk of infections + ARDS (SDRA)Chaiwat et al Anesthesiology 2009110351 n=14070 pts NSCOT database retrospective
bull Older blood association whith elevates infection LOS MOSF + death Weinberg et al J Trauma 200865279
TemperatureA temperature lt 96degF or 35degC is associated with an increase in mortality (cardiac arrest SRP higher abnormal plaquelet function) Burch J Denton J Noble R Physiologic rationale for abbreviated laparotomy Surg Clin North Am 1997 77779-82 Trauma patients that are hypothermic are NOT PERFUSING their tissue
The COAGULATION CASCADE is an enzymatic pathway that degrades with temperature and ceases at 92 FGregory JS Francbeum L Towsened MC Incidence and timing of hypothermia in trauma patients undergoing operations J Trauma 1991 31795-800 If the temperature is lower than 33 C the mortality is 100although Beilman and col think itacutes a significant factor for MODS but not for the mortalityBeilman GJ Blondet JJ Early hypothermia in severely injured trauma patients is a significant risk factor for multiple organ dysfunction syndrome but not mortality Ann Surg 2009 May249(5)845-50
Diagnosis done
Damage Control Resuscitation
1 Hypotensive resuscitation
2 Hemostatic resuscitation
Damage control philosophy can be extended to haemostatic resuscitation
Restoring normal coagulation Minimizing crystalloidTraditional resuscitation strategies dilute the already deficient coagulation factors and increase multiple organ failure
The aggressive hemostatic resuscitation should be combined with equally aggressive control of bleeding
Spahn DR Cerny V Management of bleeding following major trauma a European guidelineCrit Care 2007 11(1) R 17
WAIT AND SEE
SURGEON
ABDOMINAL PACKING is a lifesaving technique for temporary control of severe injury and it is used in damage control surgery schedule
Its possible too applying packs in organ-specific techniques (early abdominal packing)
The median survival of the 70 certainly superior to the obtainable survival with immediate surgical repairbullIMMEDIATE FAILURES are substantially due to bleeding especially in underpacking caseREMOTE FAILURES septic and bound at the time of stay (above the 72 hours) and associated by the coexistence of lesions in these situations is possible a MOF syndrome due to excessive intra-abdominal pressure (overpacking) or to an Abdominal Compartment Syndrome
Stagnitti F Bresadola L Calderale SM Coletti M Ribaldi S Salvi PF Schillaci F Abdominal packing indications and method Ann Ital Chir 2003 Sep-Oct74(5)535-42
Benavides C Garciacutea C Apablaza S Rubilar P Ricaurte F Perales C et al Empaquetamiento hepaacutetico permanente con malla de poliglactina en estallido hepaacutetico secundario a Siacutendrome de Hellp Rev Chil Cir 2004 56 275-278 De la Fuente M Mendoza VH Robledo-Oyarzun F Cierre Temporal de la pared abdominal con polietileno Cir Ciruj 2002 70157-63 Serna VH El Siacutendrome Compartamental Abdominal Tesis de Postgrado Meacutexico 2000
When skin approximation is
not possible a temporary silo
is constructed by suturing a 3-
L cystoscopy irrigation bag
(BOGOTAacute BAG) to the skin
edge with a continuous No 2
nylon suture
The method of closure depends on whether skin approximation produces excessive intra-abdominal hypertension
Towel-clip closure of the skin is preferred because it is quick and easy
The second phase is intra-operative reassessment for hemorrhage control 30 minutes after initial abdominal closure in the operating room focusing on restoration of the patients physiological status specifically reversing hypothermia and coagulopathy
WE CAN HEAR THE HEMORRHAGE
The abdomen is then reopened and assessed for adequacy of hemostasis and for existence of residual mechanical bleeding This practice has allowed surgeons to minimize both early return to the operating room for ongoing hemorrhage and the amount of packing necessary for hemostasis With bleeding effectively controlled the abdomen is reclosed
The patient is transferred to the ICU for continued physiologic restoration in the third phase
Once coagulopathy hypothermia and acidosis have been corrected the patient can be returned to the operating room for definitive management of the injuries in the fourth phase
48-72 h after first surgery
COMPLICATIONS OF DAMAGE CONTROL LAPAROTOMY
1) ACS Acute Compartmental Syndrome
2) ARDS Acute Respiratory Distress of the Adult
3) MOF Multiple organ failure
4) DEATH
ABDOMINAL COMPARTMENT SYNDROME is defined as an intra-abdominal pressure of greater than 20 cm H2O with evidence of impaired organ function ie elevated peak airway pressures (gt45 cm
H2O) oliguria (lt05 mLkg per hour) or cardiovascular dysfunction
(hypotension despite adequate volume resuscitation or if a pulmonary artery catheter is present oxygen delivery index [calculated as milliliters of oxygen per minute per meter squared] of 600) Intra-abdominal pressure was measured indirectly using an indwelling Foley catheter as previously described
Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13 Damage control surgery in the abdomen an approach for the management of severe injured patientsGermanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis NNuffield Department of Surgery John Radcliffe Hospital Oxford UK Curr Opin Crit Care 2006 Aug12(4)346-50 Damage-control laparotomy Lee JC Peitzman AB Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA
ABDOMINAL COMPARTMENT SYNDROME occurred in 17 (33) of
52 Patients undergoing damage-control laparotomy and was
associated with a much higher incidence of ARDS and MOF (71 vs
31 without ACS P = 02)
More importantly our study suggests that primary fascial closure at
the termination of the initial damage-control laparotomy contributes to
the development of ACS as well as subsequent organ failure
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal ypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
Mayberry JC Mullins RJ Crass RA Trunkey DD Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure Arch Surg 1997132957-962
bull MOF Multiple organ failure
Seems to be a major source of postinjury morbidity and the leading cause of in-hospital mortality despite more than 25 years of intense investigation
Eiseman B Beart R Norton L Multiple organ failure Surg Gynecol Obstet 1977144323-326
Bauer AE Durham R Faist E Systemic inflammatory response syndrome (SIRS) multiple organ dysfunction syndrome (MODS) multiple organ failure (MOF) are we winning the battle Shock 19981079-89
The current pathophysiologic model of MOF focuses on uncontrolled systemic
hyperinflammation as a unifying concept following a variety of insults
Moore FA Moore EE Evolving concepts in the pathogenesis of postinjury multiple organ failure Surg Clin North Am 199575257-277
Goris RJ te Boekhorst TP Nuytinck JK Gimbrere JS Multiple-organ failure generalized autodestructive inflammation Arch Surg 19851201109-1115
Nuytinck HK Offermans XJ Kubat K Goris JA Whole-body inflammation in trauma patients an autopsy study Arch Surg 19881231519-1524
Examples that improve the prognosis of MOF include damage control surgery recognition of abdominal compartment syndrome lung protective ventilation
strategies and tight glucose level control
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal hypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
The Acute Respiratory Distress Syndrome Network Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome N Engl J Med 20003421301-1308
Amato MB Barbas CS Medeiros DM et al Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome N Engl J Med 1998338347-354
Van den Berghe G Wouters P Weekers F et al Intensive insulin therapy in the critically ill patients N Engl J Med 20013451359-1367
The incidence of postinjury MOF has been reported to be between 7 and 66 with an associated mortality rate between 31 and 80
Fry DE Pearlstein L Fulton RL Polk HC Jr Multiple system organ failure the role of uncontrolled infection Arch Surg 1980115136-140
Regel G Lobenhoffer P Grotz M Pape HC Lehmann U Tscherne H Treatment results of patients with multiple trauma an analysis of 3406 cases treated between 1972 and 1991 at a German level I trauma center J Trauma 19953870-78
Sauaia A Moore FA Moore EE Norris JM Lezotte DC Hamman RF Multiple organ failure can be predicted as early as 12 hours after injury J Trauma 199845291-303
Nast-Kolb D Aufmkolk M Rucholtz S Obertacke U Waydhas C Multiple organ failure still a major cause of morbidity but not mortality in blunt multiple trauma J Trauma 200151835-842 Durham RM Moran JJ Mazuski JE Shapiro MJ Baue AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
It has been suggested that MOF is disappearing owing to advances in trauma and critical care
Levine JH Durham RM Moran J Bauer A Multiple organ failure is it disappearing World J Surg 199620471-473
Recent reports have not demonstrated a consistent change in either the incidence or the mortality rate associated with postinjury MOF Some groups have reported no change in the incidence but a decreased mortality while others have reported both decreased incidence and mortality compared with historical control subjects
Durham RM Moran JJ Mazuski JE Shapiro MJ Bauer AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
Regel G Grotz M Weltner T Sturm JA Tscherne H Pattern of organ failure following severe trauma World J Surg 199620422-429
Orthopaedic Trauma
Open pelvic fractures in addition to the pelvic ring injury are associated with hemorrhage and neurological insult visceral injuries are more common and a high rate of infection is seen Mortality of open pelvic fractures historically approached 50 Control of bleeding is the most important initial measure followed by debridement and packing of open wounds
Open book- widened symphysis pubis Dislocated Rt SI joint Vallier + Jenkins In Trauma Anesthesia 2008
Type 1 fractures occur due to anterior-posterior
compressioncan cause the symphysis pubis to ldquopoprdquo open leading to pubic rami or ldquoopen
bookrdquo fractures A lateral compression fracture type 2 or vertical sheer facture (Type 3) can
also lead to severe bleeding Into the pelvis Pelvic and acetabular surgery are major surgical interventions
Figura 1- Aplicacioacuten de la engrapadora para la reseccioacuten pulmonar en cuntildea Los segmentos a resecar se limitan por medio de la aplicacioacuten de dispositivos de grapado orientados en direcciones perpendiculares tratando de mantener la mayor cantidad de tejido sano
Insercioacuten de engrapadora lineal cortante a traveacutes de los orificios del tracto de la herida pulmonar penetrante
Figura 3- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales con fuga aeacuterea visible
Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales
Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
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Principle of Medicine
PRIMUM NON NOCEREldquoFirst do no harmrdquo
Hippocrates
ldquoDamage Control Resuscitation represents the most important advance in trauma care for hospitalized civilian and military casualties from this warrdquo
Cordts Brosch and Holcomb J Trauma 2008
His surgical technical was modified by HALSTED in 1913Garciacutea-Nuacutentildeez L Cabello R Lever C Rosales E Padilla R Garduntildeo P et alConceptos Actuales en Cirugiacutea Abdominal de Control de DantildeosComunicacioacuten acerca de donde hacer menos es hacer maacutes Trauma 2005 8 76-81
The abdominal packing has been the basement for the damage control surgery and the first phisician (military surgeon) who reported was PRINGLE in 1908
Pringle JH Notes on the arrest of hepatic hemorrhage due to trauma Ann Surg 1908 48541-9
bull In 1955 MADDING studied the temporal packing in hemorragic control after abdominal surgery
bull The MODERN era of damage-control laparotomy began with the seminal report of STONE ET AL from the Grady Memorial Hospital Atlanta Ga in 1982
Stone H Strom P Mullines R Management of the major coagulopathy with on set during laparotomy Ann Surg 1983 197532-535
bull The concept of damage control was introduced by ROTONDO y SCHWAB in patients with dangerous abdominal trauma described the three times in this surgery
Rotondo MF Mc Gonigol MD Schwab CW Kauder DR Hanson CW Damage Control An approach for improved survival in exsanguinating penetrating abdominal injury J Trauma 1993 35375-83
New Diagnostic criteriaAvoids the ldquobut he looked goodrdquo phenomenon
Within the first five minutes in the ED
Identify patients in trouble
Identify patients with increased mortality
Identify patients with increased probability of massive transfusion
The CONDUCT OF DAMAGE-CONTROL LAPAROTOMY has been described in detail elsewhere we can view the process in STAGES
Germanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis N Damage control surgery in the abdomen an approach for the management of severe injured patients Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13Lee JC Peitzman AB Nuffield Department of Surgery John Radcliffe Hospital Oxford UK Damage-control laparotomy Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA Curr Opin Crit Care 2006 Aug12(4)346-50
The MORE IMPORTANT PHASE is to IDENTIFY the appropriate candidate
bull Acidosis- Base Deficit gt - 6 phlt 72bull Coagulopathy INR gt 15 or TTPA gt 60 scbull Hypotension Systolic BP lt 90 mmHgbull Need of transfusion gt 4 l red cell contentsbull Temperature lt 96 5 F=34 Cbull Pattern recognition
bull Weak or absent radial pulse bull Abnormal mental statusbull Severe Traumatic Injury
DEATH
HYPOTHERMIA
ACIDOSIS
COAGULOPATHY
The Lethal TriadThe Lethal TriadThe Lethal TriadThe Lethal Triad
Soto S Oettinger R Brousse J Saacutenchez G Cirugiacutea de Control de Dantildeos Enfrentamiento actual del Trauma Cuad Cir 20031795-102
The OBJECTIVES are
1) STOP HEMORRHAGE to correct underlying coagulopathy
2) MINIMIZE PERITONEAL CONTAMINATION and its secondary inflammatory response
3) ENCLOSE THE ABDOMINAL CONTENTS to protect viscera and minimize protein loss
4) The final objective of this damage-control phase is CLOSURE OF THE ABDOMINAL CAVITY
bullRequires robust MEDICAL SETTING
bullNeed system approach to deliver casualties to MOST CAPABLE FACILITIES
bullIsolated and far forward facilities can still benefit from these principles
AcidosisAcidosisBASE DEFICIT (BD) ge -15 identifies patients that require early
transfusion increased ICU days and risk for ARDS and MOF Ferrara A Mac Arthur J Wright H Hypothermia and Acidosis worsen coagulopathy in the patient requiring massive transfusion Ann J Surg 1990 160515-518
bull BD of ge -15 is strongly associated with the need for massive transfusion and mortality in patients
Rutherford EJ Morris JA Reed GW Hall KS Base deficit stratifies mortality and determines therapy J Trauma 1992 33417-23
bull Patients have an elevated BD before their blood pressure drops to classic ldquohypotensionrdquo levels
bull Acidosis contributes more to coagulopathy more than hypothermia (not reversible)
bull An initial INR ge 15 reliably predicts those who will require massive transfusion
Moore FA Nelson T Massive transfusion in trauma patients tissue hemoglobin oxygen saturation predicts poor outcom J Trauma 2008 Apr 64 (4)1010-23
bull Patients who have a significant injury present with a coagulopathy
bull Severity of injury and mortality is linearly associated with the degree of the initial coagulopathy
Coagulopathy
bull Although resuscitation strategies for severely injured patients who present WITH SHOCK have improved greatly the transfusions are associated with development of MOF and increased intensive care unit (ICU) admissions ICU and hospital length of stay and mortality
bull Malone DL Dunne J Tracy JK Putnam AT Scalea TM Napolitano LM Blood
transfusion independent of shock severity is associated with worse outcome in trauma J Trauma 2003 54898-905
bull Eastridge BJ Malone D Holcomb JB Early predictors of transfusion and mortality
after injury a review of the data-based literature J Trauma 2006 60S20-S25 bull Napolitano L Cumulative risks of early red blood cell transfusion J Trauma 2006
60S26-S34 bull Cotton BA Guy JS Morris JA Jr Abumrad NN The cellular metabolic and systemic
consequences of aggressive fluid resuscitation strategies Shock 2006 26115-121
Current transfusion practices and survival rates of massive transfusion patients vary widely among trauma centers Conventional guidelines may underestimate the optimal plasma and platelet to RBC ratios
Survival in patients is associated with increased plasma and platelet ratios Massive transfusion practice guidelines should aim for a111 ratio of plasma plateletsRBCs bullHolcomb et al Ann Surg 2008248447
Kaplan-Meier survival plot for the first 24 hours after admission for the 4 groups (high plasma (FFPH) or platelet (PltH) to RBC ratio 12 low plasma (FFPL) or platelet (PltL) to RBC ratio 12)
Statistical modeling indicated that a
clinical guideline with mean plasma
RBC ratio equal to 11 would
encompass 98 of patients within
the optimal 12 ratio
Hypotension A systolic blood pressure of 90 mm Hg or less is indicative casualties that have lost over 40 of their blood volume
(~2000 ml in an adult)
They have impending cardiovascular collapse and have significantly increased mortality
The most efficient solution for use in resuscitation is still under debate
Lactated Ringers (LR) and normal isotonic saline solution (NS) remain the
most commonly used isotonic fluids
Although colloid solutions including hyperosmolar colloid and hypertonic
electrolyte compounds have been approved for use as volume expanders
their administration is still under debate in the USA and Europe
Moore FA McKinley BA Moore EE Nathens AB West M Shapiro MB Bankey P Freeman B Harbrecht BG Johnson JL Minei JP Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core standard operating procedures for clinical care III Guidelines for shock resuscitation J Trauma 2006 6182-89 Spahn DR Cerny V Coats TJ Duranteau J Fernandez-Mondejar E Gordini G Stahel PF Hunt BJ Komadina R Neugebauer E Ozier Y Riddez L Schultz A Vincent JL Rossaint R Task Force for Advanced Bleeding Care in Trauma Management of bleeding following major trauma a European guideline Crit Care 2007 11R17
Experimental studies have revealed that resuscitation with NS in the setting of massive hemorrhage requires significantly greater volume and is associated with increased physiologic derangements (for example hyperchloremic acidosis and dilutional coagulopathy) and higher mortality as compared with LR Healey MA Davis RE Liu FC Loomis WH Hoyt DB Lactated ringers is superior to normal saline in a model of massive hemorrhage and resuscitation J Trauma 1998 45894-899 Todd SR Malinoski D Muller PJ Schreiber MA Lactated Ringers is superior to normal saline in the resuscitation of uncontrolled hemorrhagic shock J Trauma 2007 62636-639
Reported data from several studies conducted in critically ill patients have indicated that use of colloid solutions has a significant impact on hemorrhage hemostasis and inflammatory response Roberts I Alderson P Bunn F Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2004 CD000567 Vercueil A Grocott MP Mythen MG Physiology pharmacology and rationale for colloid administration for the maintenance of effective hemodynamic stability in critically ill patients Transfus Med Rev 2005 1993-109 Lee CC Chang IJ Yen ZS Effect of different resuscitation fluids on cytokine response in a rat model of hemorrhagic shock Shock 2005 24177-181
Early administration of blood is one potential treatment to decrease the
need for massive crystalloid solution in hemorrhagic shock however the
limited supply of stored blood and potential adverse effects make this
option logistically difficult and possibly harmful
West MA Sha piro MB Nathens AB Johnson JL Moore EE Minei JP Bankey PE Freeman B Harbrecht BG McKinley BA Moore FA Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core-standard operating procedures for clinical care IV Guidelines for transfusion in the trauma patient J Trauma 2006 61436-439
Moore FA McKinley BA Moore EE Nathens AB West M Shapiro MB Bankey P Freeman B Harbrecht BG Johnson JL Minei JP Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core standard operating procedures for clinical care III Guidelines for shock resuscitation J Trauma 2006 6182-89 Spahn DR Cerny V Coats TJ Duranteau J Fernandez-Mondejar E Gordini G Stahel PF Hunt BJ Komadina R Neugebauer E Ozier Y Riddez L Schultz A Vincent JL Rossaint R Task Force for Advanced Bleeding Care in Trauma Management of bleeding following major trauma a European guideline Crit Care 2007 11R17
Transfusion-related risks include possible development of MOF increased
ICU admissions and length of stay increased hospital length of stay and
mortality
Malone DL Dunne J Tracy JK Putnam AT Scalea TM Napolitano LM Blood transfusion independent of shock severity is associated with worse outcome in trauma J Trauma 2003 54898-905
Eastridge BJ Malone D Holcomb JB Early predictors of transfusion and mortality after injury a review of the data-based literature J Trauma 2006 60S20-S25
Napolitano L Cumulative risks of early red blood cell transfusion J Trauma 2006 60S26-S34
Cotton BA Guy JS Morris JA Jr Abumrad NN The cellular metabolic and systemic consequences of aggressive fluid resuscitation strategies Shock 2006 26115-121
uarr hemorrhage + excessive hemodilution due to
uarr Blood Presion darr blood viscosity darr hematocrit
darr clotting factor concentration
Risks of Aggressive Volume Resuscitation
rFVIIaThe use of rFVIIa was associated with improved early and late survival after severe trauma and massive transfusion
rFVIIa was not associated with increased risk of thrombotic events
The Effect of Recombinant Activated Factor VII on Mortality in Combat-Related Casualties With Severe Trauma and Massive Transfusion
bull Philip C Spinella MD Jeremy G Perkins MD Daniel F McLaughlin MD Sarah E Niles MD MPHKurt W Grathwohl MD Alec C Beekley MD Jose Salinas PhD Sumeru Mehta MD Charles E Wade PhDand John B Holcomb MD J of Trauma- Feb 2008bull Dutton et al J Trauma 200457709 Conclusion consider early use of FVIIa in any pt with uncontrolled hemorrhage who has not responded to surgery or blood component therapy
bull Each unit of blood product biologically active + elevates risk of infections + ARDS (SDRA)Chaiwat et al Anesthesiology 2009110351 n=14070 pts NSCOT database retrospective
bull Older blood association whith elevates infection LOS MOSF + death Weinberg et al J Trauma 200865279
TemperatureA temperature lt 96degF or 35degC is associated with an increase in mortality (cardiac arrest SRP higher abnormal plaquelet function) Burch J Denton J Noble R Physiologic rationale for abbreviated laparotomy Surg Clin North Am 1997 77779-82 Trauma patients that are hypothermic are NOT PERFUSING their tissue
The COAGULATION CASCADE is an enzymatic pathway that degrades with temperature and ceases at 92 FGregory JS Francbeum L Towsened MC Incidence and timing of hypothermia in trauma patients undergoing operations J Trauma 1991 31795-800 If the temperature is lower than 33 C the mortality is 100although Beilman and col think itacutes a significant factor for MODS but not for the mortalityBeilman GJ Blondet JJ Early hypothermia in severely injured trauma patients is a significant risk factor for multiple organ dysfunction syndrome but not mortality Ann Surg 2009 May249(5)845-50
Diagnosis done
Damage Control Resuscitation
1 Hypotensive resuscitation
2 Hemostatic resuscitation
Damage control philosophy can be extended to haemostatic resuscitation
Restoring normal coagulation Minimizing crystalloidTraditional resuscitation strategies dilute the already deficient coagulation factors and increase multiple organ failure
The aggressive hemostatic resuscitation should be combined with equally aggressive control of bleeding
Spahn DR Cerny V Management of bleeding following major trauma a European guidelineCrit Care 2007 11(1) R 17
WAIT AND SEE
SURGEON
ABDOMINAL PACKING is a lifesaving technique for temporary control of severe injury and it is used in damage control surgery schedule
Its possible too applying packs in organ-specific techniques (early abdominal packing)
The median survival of the 70 certainly superior to the obtainable survival with immediate surgical repairbullIMMEDIATE FAILURES are substantially due to bleeding especially in underpacking caseREMOTE FAILURES septic and bound at the time of stay (above the 72 hours) and associated by the coexistence of lesions in these situations is possible a MOF syndrome due to excessive intra-abdominal pressure (overpacking) or to an Abdominal Compartment Syndrome
Stagnitti F Bresadola L Calderale SM Coletti M Ribaldi S Salvi PF Schillaci F Abdominal packing indications and method Ann Ital Chir 2003 Sep-Oct74(5)535-42
Benavides C Garciacutea C Apablaza S Rubilar P Ricaurte F Perales C et al Empaquetamiento hepaacutetico permanente con malla de poliglactina en estallido hepaacutetico secundario a Siacutendrome de Hellp Rev Chil Cir 2004 56 275-278 De la Fuente M Mendoza VH Robledo-Oyarzun F Cierre Temporal de la pared abdominal con polietileno Cir Ciruj 2002 70157-63 Serna VH El Siacutendrome Compartamental Abdominal Tesis de Postgrado Meacutexico 2000
When skin approximation is
not possible a temporary silo
is constructed by suturing a 3-
L cystoscopy irrigation bag
(BOGOTAacute BAG) to the skin
edge with a continuous No 2
nylon suture
The method of closure depends on whether skin approximation produces excessive intra-abdominal hypertension
Towel-clip closure of the skin is preferred because it is quick and easy
The second phase is intra-operative reassessment for hemorrhage control 30 minutes after initial abdominal closure in the operating room focusing on restoration of the patients physiological status specifically reversing hypothermia and coagulopathy
WE CAN HEAR THE HEMORRHAGE
The abdomen is then reopened and assessed for adequacy of hemostasis and for existence of residual mechanical bleeding This practice has allowed surgeons to minimize both early return to the operating room for ongoing hemorrhage and the amount of packing necessary for hemostasis With bleeding effectively controlled the abdomen is reclosed
The patient is transferred to the ICU for continued physiologic restoration in the third phase
Once coagulopathy hypothermia and acidosis have been corrected the patient can be returned to the operating room for definitive management of the injuries in the fourth phase
48-72 h after first surgery
COMPLICATIONS OF DAMAGE CONTROL LAPAROTOMY
1) ACS Acute Compartmental Syndrome
2) ARDS Acute Respiratory Distress of the Adult
3) MOF Multiple organ failure
4) DEATH
ABDOMINAL COMPARTMENT SYNDROME is defined as an intra-abdominal pressure of greater than 20 cm H2O with evidence of impaired organ function ie elevated peak airway pressures (gt45 cm
H2O) oliguria (lt05 mLkg per hour) or cardiovascular dysfunction
(hypotension despite adequate volume resuscitation or if a pulmonary artery catheter is present oxygen delivery index [calculated as milliliters of oxygen per minute per meter squared] of 600) Intra-abdominal pressure was measured indirectly using an indwelling Foley catheter as previously described
Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13 Damage control surgery in the abdomen an approach for the management of severe injured patientsGermanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis NNuffield Department of Surgery John Radcliffe Hospital Oxford UK Curr Opin Crit Care 2006 Aug12(4)346-50 Damage-control laparotomy Lee JC Peitzman AB Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA
ABDOMINAL COMPARTMENT SYNDROME occurred in 17 (33) of
52 Patients undergoing damage-control laparotomy and was
associated with a much higher incidence of ARDS and MOF (71 vs
31 without ACS P = 02)
More importantly our study suggests that primary fascial closure at
the termination of the initial damage-control laparotomy contributes to
the development of ACS as well as subsequent organ failure
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal ypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
Mayberry JC Mullins RJ Crass RA Trunkey DD Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure Arch Surg 1997132957-962
bull MOF Multiple organ failure
Seems to be a major source of postinjury morbidity and the leading cause of in-hospital mortality despite more than 25 years of intense investigation
Eiseman B Beart R Norton L Multiple organ failure Surg Gynecol Obstet 1977144323-326
Bauer AE Durham R Faist E Systemic inflammatory response syndrome (SIRS) multiple organ dysfunction syndrome (MODS) multiple organ failure (MOF) are we winning the battle Shock 19981079-89
The current pathophysiologic model of MOF focuses on uncontrolled systemic
hyperinflammation as a unifying concept following a variety of insults
Moore FA Moore EE Evolving concepts in the pathogenesis of postinjury multiple organ failure Surg Clin North Am 199575257-277
Goris RJ te Boekhorst TP Nuytinck JK Gimbrere JS Multiple-organ failure generalized autodestructive inflammation Arch Surg 19851201109-1115
Nuytinck HK Offermans XJ Kubat K Goris JA Whole-body inflammation in trauma patients an autopsy study Arch Surg 19881231519-1524
Examples that improve the prognosis of MOF include damage control surgery recognition of abdominal compartment syndrome lung protective ventilation
strategies and tight glucose level control
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal hypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
The Acute Respiratory Distress Syndrome Network Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome N Engl J Med 20003421301-1308
Amato MB Barbas CS Medeiros DM et al Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome N Engl J Med 1998338347-354
Van den Berghe G Wouters P Weekers F et al Intensive insulin therapy in the critically ill patients N Engl J Med 20013451359-1367
The incidence of postinjury MOF has been reported to be between 7 and 66 with an associated mortality rate between 31 and 80
Fry DE Pearlstein L Fulton RL Polk HC Jr Multiple system organ failure the role of uncontrolled infection Arch Surg 1980115136-140
Regel G Lobenhoffer P Grotz M Pape HC Lehmann U Tscherne H Treatment results of patients with multiple trauma an analysis of 3406 cases treated between 1972 and 1991 at a German level I trauma center J Trauma 19953870-78
Sauaia A Moore FA Moore EE Norris JM Lezotte DC Hamman RF Multiple organ failure can be predicted as early as 12 hours after injury J Trauma 199845291-303
Nast-Kolb D Aufmkolk M Rucholtz S Obertacke U Waydhas C Multiple organ failure still a major cause of morbidity but not mortality in blunt multiple trauma J Trauma 200151835-842 Durham RM Moran JJ Mazuski JE Shapiro MJ Baue AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
It has been suggested that MOF is disappearing owing to advances in trauma and critical care
Levine JH Durham RM Moran J Bauer A Multiple organ failure is it disappearing World J Surg 199620471-473
Recent reports have not demonstrated a consistent change in either the incidence or the mortality rate associated with postinjury MOF Some groups have reported no change in the incidence but a decreased mortality while others have reported both decreased incidence and mortality compared with historical control subjects
Durham RM Moran JJ Mazuski JE Shapiro MJ Bauer AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
Regel G Grotz M Weltner T Sturm JA Tscherne H Pattern of organ failure following severe trauma World J Surg 199620422-429
Orthopaedic Trauma
Open pelvic fractures in addition to the pelvic ring injury are associated with hemorrhage and neurological insult visceral injuries are more common and a high rate of infection is seen Mortality of open pelvic fractures historically approached 50 Control of bleeding is the most important initial measure followed by debridement and packing of open wounds
Open book- widened symphysis pubis Dislocated Rt SI joint Vallier + Jenkins In Trauma Anesthesia 2008
Type 1 fractures occur due to anterior-posterior
compressioncan cause the symphysis pubis to ldquopoprdquo open leading to pubic rami or ldquoopen
bookrdquo fractures A lateral compression fracture type 2 or vertical sheer facture (Type 3) can
also lead to severe bleeding Into the pelvis Pelvic and acetabular surgery are major surgical interventions
Figura 1- Aplicacioacuten de la engrapadora para la reseccioacuten pulmonar en cuntildea Los segmentos a resecar se limitan por medio de la aplicacioacuten de dispositivos de grapado orientados en direcciones perpendiculares tratando de mantener la mayor cantidad de tejido sano
Insercioacuten de engrapadora lineal cortante a traveacutes de los orificios del tracto de la herida pulmonar penetrante
Figura 3- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales con fuga aeacuterea visible
Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales
Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
- Slide 1
- Slide 2
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
- Slide 10
- Slide 11
- Slide 12
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- Slide 31
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Slide 36
- Slide 37
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
ldquoDamage Control Resuscitation represents the most important advance in trauma care for hospitalized civilian and military casualties from this warrdquo
Cordts Brosch and Holcomb J Trauma 2008
His surgical technical was modified by HALSTED in 1913Garciacutea-Nuacutentildeez L Cabello R Lever C Rosales E Padilla R Garduntildeo P et alConceptos Actuales en Cirugiacutea Abdominal de Control de DantildeosComunicacioacuten acerca de donde hacer menos es hacer maacutes Trauma 2005 8 76-81
The abdominal packing has been the basement for the damage control surgery and the first phisician (military surgeon) who reported was PRINGLE in 1908
Pringle JH Notes on the arrest of hepatic hemorrhage due to trauma Ann Surg 1908 48541-9
bull In 1955 MADDING studied the temporal packing in hemorragic control after abdominal surgery
bull The MODERN era of damage-control laparotomy began with the seminal report of STONE ET AL from the Grady Memorial Hospital Atlanta Ga in 1982
Stone H Strom P Mullines R Management of the major coagulopathy with on set during laparotomy Ann Surg 1983 197532-535
bull The concept of damage control was introduced by ROTONDO y SCHWAB in patients with dangerous abdominal trauma described the three times in this surgery
Rotondo MF Mc Gonigol MD Schwab CW Kauder DR Hanson CW Damage Control An approach for improved survival in exsanguinating penetrating abdominal injury J Trauma 1993 35375-83
New Diagnostic criteriaAvoids the ldquobut he looked goodrdquo phenomenon
Within the first five minutes in the ED
Identify patients in trouble
Identify patients with increased mortality
Identify patients with increased probability of massive transfusion
The CONDUCT OF DAMAGE-CONTROL LAPAROTOMY has been described in detail elsewhere we can view the process in STAGES
Germanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis N Damage control surgery in the abdomen an approach for the management of severe injured patients Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13Lee JC Peitzman AB Nuffield Department of Surgery John Radcliffe Hospital Oxford UK Damage-control laparotomy Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA Curr Opin Crit Care 2006 Aug12(4)346-50
The MORE IMPORTANT PHASE is to IDENTIFY the appropriate candidate
bull Acidosis- Base Deficit gt - 6 phlt 72bull Coagulopathy INR gt 15 or TTPA gt 60 scbull Hypotension Systolic BP lt 90 mmHgbull Need of transfusion gt 4 l red cell contentsbull Temperature lt 96 5 F=34 Cbull Pattern recognition
bull Weak or absent radial pulse bull Abnormal mental statusbull Severe Traumatic Injury
DEATH
HYPOTHERMIA
ACIDOSIS
COAGULOPATHY
The Lethal TriadThe Lethal TriadThe Lethal TriadThe Lethal Triad
Soto S Oettinger R Brousse J Saacutenchez G Cirugiacutea de Control de Dantildeos Enfrentamiento actual del Trauma Cuad Cir 20031795-102
The OBJECTIVES are
1) STOP HEMORRHAGE to correct underlying coagulopathy
2) MINIMIZE PERITONEAL CONTAMINATION and its secondary inflammatory response
3) ENCLOSE THE ABDOMINAL CONTENTS to protect viscera and minimize protein loss
4) The final objective of this damage-control phase is CLOSURE OF THE ABDOMINAL CAVITY
bullRequires robust MEDICAL SETTING
bullNeed system approach to deliver casualties to MOST CAPABLE FACILITIES
bullIsolated and far forward facilities can still benefit from these principles
AcidosisAcidosisBASE DEFICIT (BD) ge -15 identifies patients that require early
transfusion increased ICU days and risk for ARDS and MOF Ferrara A Mac Arthur J Wright H Hypothermia and Acidosis worsen coagulopathy in the patient requiring massive transfusion Ann J Surg 1990 160515-518
bull BD of ge -15 is strongly associated with the need for massive transfusion and mortality in patients
Rutherford EJ Morris JA Reed GW Hall KS Base deficit stratifies mortality and determines therapy J Trauma 1992 33417-23
bull Patients have an elevated BD before their blood pressure drops to classic ldquohypotensionrdquo levels
bull Acidosis contributes more to coagulopathy more than hypothermia (not reversible)
bull An initial INR ge 15 reliably predicts those who will require massive transfusion
Moore FA Nelson T Massive transfusion in trauma patients tissue hemoglobin oxygen saturation predicts poor outcom J Trauma 2008 Apr 64 (4)1010-23
bull Patients who have a significant injury present with a coagulopathy
bull Severity of injury and mortality is linearly associated with the degree of the initial coagulopathy
Coagulopathy
bull Although resuscitation strategies for severely injured patients who present WITH SHOCK have improved greatly the transfusions are associated with development of MOF and increased intensive care unit (ICU) admissions ICU and hospital length of stay and mortality
bull Malone DL Dunne J Tracy JK Putnam AT Scalea TM Napolitano LM Blood
transfusion independent of shock severity is associated with worse outcome in trauma J Trauma 2003 54898-905
bull Eastridge BJ Malone D Holcomb JB Early predictors of transfusion and mortality
after injury a review of the data-based literature J Trauma 2006 60S20-S25 bull Napolitano L Cumulative risks of early red blood cell transfusion J Trauma 2006
60S26-S34 bull Cotton BA Guy JS Morris JA Jr Abumrad NN The cellular metabolic and systemic
consequences of aggressive fluid resuscitation strategies Shock 2006 26115-121
Current transfusion practices and survival rates of massive transfusion patients vary widely among trauma centers Conventional guidelines may underestimate the optimal plasma and platelet to RBC ratios
Survival in patients is associated with increased plasma and platelet ratios Massive transfusion practice guidelines should aim for a111 ratio of plasma plateletsRBCs bullHolcomb et al Ann Surg 2008248447
Kaplan-Meier survival plot for the first 24 hours after admission for the 4 groups (high plasma (FFPH) or platelet (PltH) to RBC ratio 12 low plasma (FFPL) or platelet (PltL) to RBC ratio 12)
Statistical modeling indicated that a
clinical guideline with mean plasma
RBC ratio equal to 11 would
encompass 98 of patients within
the optimal 12 ratio
Hypotension A systolic blood pressure of 90 mm Hg or less is indicative casualties that have lost over 40 of their blood volume
(~2000 ml in an adult)
They have impending cardiovascular collapse and have significantly increased mortality
The most efficient solution for use in resuscitation is still under debate
Lactated Ringers (LR) and normal isotonic saline solution (NS) remain the
most commonly used isotonic fluids
Although colloid solutions including hyperosmolar colloid and hypertonic
electrolyte compounds have been approved for use as volume expanders
their administration is still under debate in the USA and Europe
Moore FA McKinley BA Moore EE Nathens AB West M Shapiro MB Bankey P Freeman B Harbrecht BG Johnson JL Minei JP Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core standard operating procedures for clinical care III Guidelines for shock resuscitation J Trauma 2006 6182-89 Spahn DR Cerny V Coats TJ Duranteau J Fernandez-Mondejar E Gordini G Stahel PF Hunt BJ Komadina R Neugebauer E Ozier Y Riddez L Schultz A Vincent JL Rossaint R Task Force for Advanced Bleeding Care in Trauma Management of bleeding following major trauma a European guideline Crit Care 2007 11R17
Experimental studies have revealed that resuscitation with NS in the setting of massive hemorrhage requires significantly greater volume and is associated with increased physiologic derangements (for example hyperchloremic acidosis and dilutional coagulopathy) and higher mortality as compared with LR Healey MA Davis RE Liu FC Loomis WH Hoyt DB Lactated ringers is superior to normal saline in a model of massive hemorrhage and resuscitation J Trauma 1998 45894-899 Todd SR Malinoski D Muller PJ Schreiber MA Lactated Ringers is superior to normal saline in the resuscitation of uncontrolled hemorrhagic shock J Trauma 2007 62636-639
Reported data from several studies conducted in critically ill patients have indicated that use of colloid solutions has a significant impact on hemorrhage hemostasis and inflammatory response Roberts I Alderson P Bunn F Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2004 CD000567 Vercueil A Grocott MP Mythen MG Physiology pharmacology and rationale for colloid administration for the maintenance of effective hemodynamic stability in critically ill patients Transfus Med Rev 2005 1993-109 Lee CC Chang IJ Yen ZS Effect of different resuscitation fluids on cytokine response in a rat model of hemorrhagic shock Shock 2005 24177-181
Early administration of blood is one potential treatment to decrease the
need for massive crystalloid solution in hemorrhagic shock however the
limited supply of stored blood and potential adverse effects make this
option logistically difficult and possibly harmful
West MA Sha piro MB Nathens AB Johnson JL Moore EE Minei JP Bankey PE Freeman B Harbrecht BG McKinley BA Moore FA Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core-standard operating procedures for clinical care IV Guidelines for transfusion in the trauma patient J Trauma 2006 61436-439
Moore FA McKinley BA Moore EE Nathens AB West M Shapiro MB Bankey P Freeman B Harbrecht BG Johnson JL Minei JP Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core standard operating procedures for clinical care III Guidelines for shock resuscitation J Trauma 2006 6182-89 Spahn DR Cerny V Coats TJ Duranteau J Fernandez-Mondejar E Gordini G Stahel PF Hunt BJ Komadina R Neugebauer E Ozier Y Riddez L Schultz A Vincent JL Rossaint R Task Force for Advanced Bleeding Care in Trauma Management of bleeding following major trauma a European guideline Crit Care 2007 11R17
Transfusion-related risks include possible development of MOF increased
ICU admissions and length of stay increased hospital length of stay and
mortality
Malone DL Dunne J Tracy JK Putnam AT Scalea TM Napolitano LM Blood transfusion independent of shock severity is associated with worse outcome in trauma J Trauma 2003 54898-905
Eastridge BJ Malone D Holcomb JB Early predictors of transfusion and mortality after injury a review of the data-based literature J Trauma 2006 60S20-S25
Napolitano L Cumulative risks of early red blood cell transfusion J Trauma 2006 60S26-S34
Cotton BA Guy JS Morris JA Jr Abumrad NN The cellular metabolic and systemic consequences of aggressive fluid resuscitation strategies Shock 2006 26115-121
uarr hemorrhage + excessive hemodilution due to
uarr Blood Presion darr blood viscosity darr hematocrit
darr clotting factor concentration
Risks of Aggressive Volume Resuscitation
rFVIIaThe use of rFVIIa was associated with improved early and late survival after severe trauma and massive transfusion
rFVIIa was not associated with increased risk of thrombotic events
The Effect of Recombinant Activated Factor VII on Mortality in Combat-Related Casualties With Severe Trauma and Massive Transfusion
bull Philip C Spinella MD Jeremy G Perkins MD Daniel F McLaughlin MD Sarah E Niles MD MPHKurt W Grathwohl MD Alec C Beekley MD Jose Salinas PhD Sumeru Mehta MD Charles E Wade PhDand John B Holcomb MD J of Trauma- Feb 2008bull Dutton et al J Trauma 200457709 Conclusion consider early use of FVIIa in any pt with uncontrolled hemorrhage who has not responded to surgery or blood component therapy
bull Each unit of blood product biologically active + elevates risk of infections + ARDS (SDRA)Chaiwat et al Anesthesiology 2009110351 n=14070 pts NSCOT database retrospective
bull Older blood association whith elevates infection LOS MOSF + death Weinberg et al J Trauma 200865279
TemperatureA temperature lt 96degF or 35degC is associated with an increase in mortality (cardiac arrest SRP higher abnormal plaquelet function) Burch J Denton J Noble R Physiologic rationale for abbreviated laparotomy Surg Clin North Am 1997 77779-82 Trauma patients that are hypothermic are NOT PERFUSING their tissue
The COAGULATION CASCADE is an enzymatic pathway that degrades with temperature and ceases at 92 FGregory JS Francbeum L Towsened MC Incidence and timing of hypothermia in trauma patients undergoing operations J Trauma 1991 31795-800 If the temperature is lower than 33 C the mortality is 100although Beilman and col think itacutes a significant factor for MODS but not for the mortalityBeilman GJ Blondet JJ Early hypothermia in severely injured trauma patients is a significant risk factor for multiple organ dysfunction syndrome but not mortality Ann Surg 2009 May249(5)845-50
Diagnosis done
Damage Control Resuscitation
1 Hypotensive resuscitation
2 Hemostatic resuscitation
Damage control philosophy can be extended to haemostatic resuscitation
Restoring normal coagulation Minimizing crystalloidTraditional resuscitation strategies dilute the already deficient coagulation factors and increase multiple organ failure
The aggressive hemostatic resuscitation should be combined with equally aggressive control of bleeding
Spahn DR Cerny V Management of bleeding following major trauma a European guidelineCrit Care 2007 11(1) R 17
WAIT AND SEE
SURGEON
ABDOMINAL PACKING is a lifesaving technique for temporary control of severe injury and it is used in damage control surgery schedule
Its possible too applying packs in organ-specific techniques (early abdominal packing)
The median survival of the 70 certainly superior to the obtainable survival with immediate surgical repairbullIMMEDIATE FAILURES are substantially due to bleeding especially in underpacking caseREMOTE FAILURES septic and bound at the time of stay (above the 72 hours) and associated by the coexistence of lesions in these situations is possible a MOF syndrome due to excessive intra-abdominal pressure (overpacking) or to an Abdominal Compartment Syndrome
Stagnitti F Bresadola L Calderale SM Coletti M Ribaldi S Salvi PF Schillaci F Abdominal packing indications and method Ann Ital Chir 2003 Sep-Oct74(5)535-42
Benavides C Garciacutea C Apablaza S Rubilar P Ricaurte F Perales C et al Empaquetamiento hepaacutetico permanente con malla de poliglactina en estallido hepaacutetico secundario a Siacutendrome de Hellp Rev Chil Cir 2004 56 275-278 De la Fuente M Mendoza VH Robledo-Oyarzun F Cierre Temporal de la pared abdominal con polietileno Cir Ciruj 2002 70157-63 Serna VH El Siacutendrome Compartamental Abdominal Tesis de Postgrado Meacutexico 2000
When skin approximation is
not possible a temporary silo
is constructed by suturing a 3-
L cystoscopy irrigation bag
(BOGOTAacute BAG) to the skin
edge with a continuous No 2
nylon suture
The method of closure depends on whether skin approximation produces excessive intra-abdominal hypertension
Towel-clip closure of the skin is preferred because it is quick and easy
The second phase is intra-operative reassessment for hemorrhage control 30 minutes after initial abdominal closure in the operating room focusing on restoration of the patients physiological status specifically reversing hypothermia and coagulopathy
WE CAN HEAR THE HEMORRHAGE
The abdomen is then reopened and assessed for adequacy of hemostasis and for existence of residual mechanical bleeding This practice has allowed surgeons to minimize both early return to the operating room for ongoing hemorrhage and the amount of packing necessary for hemostasis With bleeding effectively controlled the abdomen is reclosed
The patient is transferred to the ICU for continued physiologic restoration in the third phase
Once coagulopathy hypothermia and acidosis have been corrected the patient can be returned to the operating room for definitive management of the injuries in the fourth phase
48-72 h after first surgery
COMPLICATIONS OF DAMAGE CONTROL LAPAROTOMY
1) ACS Acute Compartmental Syndrome
2) ARDS Acute Respiratory Distress of the Adult
3) MOF Multiple organ failure
4) DEATH
ABDOMINAL COMPARTMENT SYNDROME is defined as an intra-abdominal pressure of greater than 20 cm H2O with evidence of impaired organ function ie elevated peak airway pressures (gt45 cm
H2O) oliguria (lt05 mLkg per hour) or cardiovascular dysfunction
(hypotension despite adequate volume resuscitation or if a pulmonary artery catheter is present oxygen delivery index [calculated as milliliters of oxygen per minute per meter squared] of 600) Intra-abdominal pressure was measured indirectly using an indwelling Foley catheter as previously described
Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13 Damage control surgery in the abdomen an approach for the management of severe injured patientsGermanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis NNuffield Department of Surgery John Radcliffe Hospital Oxford UK Curr Opin Crit Care 2006 Aug12(4)346-50 Damage-control laparotomy Lee JC Peitzman AB Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA
ABDOMINAL COMPARTMENT SYNDROME occurred in 17 (33) of
52 Patients undergoing damage-control laparotomy and was
associated with a much higher incidence of ARDS and MOF (71 vs
31 without ACS P = 02)
More importantly our study suggests that primary fascial closure at
the termination of the initial damage-control laparotomy contributes to
the development of ACS as well as subsequent organ failure
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal ypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
Mayberry JC Mullins RJ Crass RA Trunkey DD Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure Arch Surg 1997132957-962
bull MOF Multiple organ failure
Seems to be a major source of postinjury morbidity and the leading cause of in-hospital mortality despite more than 25 years of intense investigation
Eiseman B Beart R Norton L Multiple organ failure Surg Gynecol Obstet 1977144323-326
Bauer AE Durham R Faist E Systemic inflammatory response syndrome (SIRS) multiple organ dysfunction syndrome (MODS) multiple organ failure (MOF) are we winning the battle Shock 19981079-89
The current pathophysiologic model of MOF focuses on uncontrolled systemic
hyperinflammation as a unifying concept following a variety of insults
Moore FA Moore EE Evolving concepts in the pathogenesis of postinjury multiple organ failure Surg Clin North Am 199575257-277
Goris RJ te Boekhorst TP Nuytinck JK Gimbrere JS Multiple-organ failure generalized autodestructive inflammation Arch Surg 19851201109-1115
Nuytinck HK Offermans XJ Kubat K Goris JA Whole-body inflammation in trauma patients an autopsy study Arch Surg 19881231519-1524
Examples that improve the prognosis of MOF include damage control surgery recognition of abdominal compartment syndrome lung protective ventilation
strategies and tight glucose level control
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal hypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
The Acute Respiratory Distress Syndrome Network Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome N Engl J Med 20003421301-1308
Amato MB Barbas CS Medeiros DM et al Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome N Engl J Med 1998338347-354
Van den Berghe G Wouters P Weekers F et al Intensive insulin therapy in the critically ill patients N Engl J Med 20013451359-1367
The incidence of postinjury MOF has been reported to be between 7 and 66 with an associated mortality rate between 31 and 80
Fry DE Pearlstein L Fulton RL Polk HC Jr Multiple system organ failure the role of uncontrolled infection Arch Surg 1980115136-140
Regel G Lobenhoffer P Grotz M Pape HC Lehmann U Tscherne H Treatment results of patients with multiple trauma an analysis of 3406 cases treated between 1972 and 1991 at a German level I trauma center J Trauma 19953870-78
Sauaia A Moore FA Moore EE Norris JM Lezotte DC Hamman RF Multiple organ failure can be predicted as early as 12 hours after injury J Trauma 199845291-303
Nast-Kolb D Aufmkolk M Rucholtz S Obertacke U Waydhas C Multiple organ failure still a major cause of morbidity but not mortality in blunt multiple trauma J Trauma 200151835-842 Durham RM Moran JJ Mazuski JE Shapiro MJ Baue AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
It has been suggested that MOF is disappearing owing to advances in trauma and critical care
Levine JH Durham RM Moran J Bauer A Multiple organ failure is it disappearing World J Surg 199620471-473
Recent reports have not demonstrated a consistent change in either the incidence or the mortality rate associated with postinjury MOF Some groups have reported no change in the incidence but a decreased mortality while others have reported both decreased incidence and mortality compared with historical control subjects
Durham RM Moran JJ Mazuski JE Shapiro MJ Bauer AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
Regel G Grotz M Weltner T Sturm JA Tscherne H Pattern of organ failure following severe trauma World J Surg 199620422-429
Orthopaedic Trauma
Open pelvic fractures in addition to the pelvic ring injury are associated with hemorrhage and neurological insult visceral injuries are more common and a high rate of infection is seen Mortality of open pelvic fractures historically approached 50 Control of bleeding is the most important initial measure followed by debridement and packing of open wounds
Open book- widened symphysis pubis Dislocated Rt SI joint Vallier + Jenkins In Trauma Anesthesia 2008
Type 1 fractures occur due to anterior-posterior
compressioncan cause the symphysis pubis to ldquopoprdquo open leading to pubic rami or ldquoopen
bookrdquo fractures A lateral compression fracture type 2 or vertical sheer facture (Type 3) can
also lead to severe bleeding Into the pelvis Pelvic and acetabular surgery are major surgical interventions
Figura 1- Aplicacioacuten de la engrapadora para la reseccioacuten pulmonar en cuntildea Los segmentos a resecar se limitan por medio de la aplicacioacuten de dispositivos de grapado orientados en direcciones perpendiculares tratando de mantener la mayor cantidad de tejido sano
Insercioacuten de engrapadora lineal cortante a traveacutes de los orificios del tracto de la herida pulmonar penetrante
Figura 3- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales con fuga aeacuterea visible
Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales
Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
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-
His surgical technical was modified by HALSTED in 1913Garciacutea-Nuacutentildeez L Cabello R Lever C Rosales E Padilla R Garduntildeo P et alConceptos Actuales en Cirugiacutea Abdominal de Control de DantildeosComunicacioacuten acerca de donde hacer menos es hacer maacutes Trauma 2005 8 76-81
The abdominal packing has been the basement for the damage control surgery and the first phisician (military surgeon) who reported was PRINGLE in 1908
Pringle JH Notes on the arrest of hepatic hemorrhage due to trauma Ann Surg 1908 48541-9
bull In 1955 MADDING studied the temporal packing in hemorragic control after abdominal surgery
bull The MODERN era of damage-control laparotomy began with the seminal report of STONE ET AL from the Grady Memorial Hospital Atlanta Ga in 1982
Stone H Strom P Mullines R Management of the major coagulopathy with on set during laparotomy Ann Surg 1983 197532-535
bull The concept of damage control was introduced by ROTONDO y SCHWAB in patients with dangerous abdominal trauma described the three times in this surgery
Rotondo MF Mc Gonigol MD Schwab CW Kauder DR Hanson CW Damage Control An approach for improved survival in exsanguinating penetrating abdominal injury J Trauma 1993 35375-83
New Diagnostic criteriaAvoids the ldquobut he looked goodrdquo phenomenon
Within the first five minutes in the ED
Identify patients in trouble
Identify patients with increased mortality
Identify patients with increased probability of massive transfusion
The CONDUCT OF DAMAGE-CONTROL LAPAROTOMY has been described in detail elsewhere we can view the process in STAGES
Germanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis N Damage control surgery in the abdomen an approach for the management of severe injured patients Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13Lee JC Peitzman AB Nuffield Department of Surgery John Radcliffe Hospital Oxford UK Damage-control laparotomy Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA Curr Opin Crit Care 2006 Aug12(4)346-50
The MORE IMPORTANT PHASE is to IDENTIFY the appropriate candidate
bull Acidosis- Base Deficit gt - 6 phlt 72bull Coagulopathy INR gt 15 or TTPA gt 60 scbull Hypotension Systolic BP lt 90 mmHgbull Need of transfusion gt 4 l red cell contentsbull Temperature lt 96 5 F=34 Cbull Pattern recognition
bull Weak or absent radial pulse bull Abnormal mental statusbull Severe Traumatic Injury
DEATH
HYPOTHERMIA
ACIDOSIS
COAGULOPATHY
The Lethal TriadThe Lethal TriadThe Lethal TriadThe Lethal Triad
Soto S Oettinger R Brousse J Saacutenchez G Cirugiacutea de Control de Dantildeos Enfrentamiento actual del Trauma Cuad Cir 20031795-102
The OBJECTIVES are
1) STOP HEMORRHAGE to correct underlying coagulopathy
2) MINIMIZE PERITONEAL CONTAMINATION and its secondary inflammatory response
3) ENCLOSE THE ABDOMINAL CONTENTS to protect viscera and minimize protein loss
4) The final objective of this damage-control phase is CLOSURE OF THE ABDOMINAL CAVITY
bullRequires robust MEDICAL SETTING
bullNeed system approach to deliver casualties to MOST CAPABLE FACILITIES
bullIsolated and far forward facilities can still benefit from these principles
AcidosisAcidosisBASE DEFICIT (BD) ge -15 identifies patients that require early
transfusion increased ICU days and risk for ARDS and MOF Ferrara A Mac Arthur J Wright H Hypothermia and Acidosis worsen coagulopathy in the patient requiring massive transfusion Ann J Surg 1990 160515-518
bull BD of ge -15 is strongly associated with the need for massive transfusion and mortality in patients
Rutherford EJ Morris JA Reed GW Hall KS Base deficit stratifies mortality and determines therapy J Trauma 1992 33417-23
bull Patients have an elevated BD before their blood pressure drops to classic ldquohypotensionrdquo levels
bull Acidosis contributes more to coagulopathy more than hypothermia (not reversible)
bull An initial INR ge 15 reliably predicts those who will require massive transfusion
Moore FA Nelson T Massive transfusion in trauma patients tissue hemoglobin oxygen saturation predicts poor outcom J Trauma 2008 Apr 64 (4)1010-23
bull Patients who have a significant injury present with a coagulopathy
bull Severity of injury and mortality is linearly associated with the degree of the initial coagulopathy
Coagulopathy
bull Although resuscitation strategies for severely injured patients who present WITH SHOCK have improved greatly the transfusions are associated with development of MOF and increased intensive care unit (ICU) admissions ICU and hospital length of stay and mortality
bull Malone DL Dunne J Tracy JK Putnam AT Scalea TM Napolitano LM Blood
transfusion independent of shock severity is associated with worse outcome in trauma J Trauma 2003 54898-905
bull Eastridge BJ Malone D Holcomb JB Early predictors of transfusion and mortality
after injury a review of the data-based literature J Trauma 2006 60S20-S25 bull Napolitano L Cumulative risks of early red blood cell transfusion J Trauma 2006
60S26-S34 bull Cotton BA Guy JS Morris JA Jr Abumrad NN The cellular metabolic and systemic
consequences of aggressive fluid resuscitation strategies Shock 2006 26115-121
Current transfusion practices and survival rates of massive transfusion patients vary widely among trauma centers Conventional guidelines may underestimate the optimal plasma and platelet to RBC ratios
Survival in patients is associated with increased plasma and platelet ratios Massive transfusion practice guidelines should aim for a111 ratio of plasma plateletsRBCs bullHolcomb et al Ann Surg 2008248447
Kaplan-Meier survival plot for the first 24 hours after admission for the 4 groups (high plasma (FFPH) or platelet (PltH) to RBC ratio 12 low plasma (FFPL) or platelet (PltL) to RBC ratio 12)
Statistical modeling indicated that a
clinical guideline with mean plasma
RBC ratio equal to 11 would
encompass 98 of patients within
the optimal 12 ratio
Hypotension A systolic blood pressure of 90 mm Hg or less is indicative casualties that have lost over 40 of their blood volume
(~2000 ml in an adult)
They have impending cardiovascular collapse and have significantly increased mortality
The most efficient solution for use in resuscitation is still under debate
Lactated Ringers (LR) and normal isotonic saline solution (NS) remain the
most commonly used isotonic fluids
Although colloid solutions including hyperosmolar colloid and hypertonic
electrolyte compounds have been approved for use as volume expanders
their administration is still under debate in the USA and Europe
Moore FA McKinley BA Moore EE Nathens AB West M Shapiro MB Bankey P Freeman B Harbrecht BG Johnson JL Minei JP Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core standard operating procedures for clinical care III Guidelines for shock resuscitation J Trauma 2006 6182-89 Spahn DR Cerny V Coats TJ Duranteau J Fernandez-Mondejar E Gordini G Stahel PF Hunt BJ Komadina R Neugebauer E Ozier Y Riddez L Schultz A Vincent JL Rossaint R Task Force for Advanced Bleeding Care in Trauma Management of bleeding following major trauma a European guideline Crit Care 2007 11R17
Experimental studies have revealed that resuscitation with NS in the setting of massive hemorrhage requires significantly greater volume and is associated with increased physiologic derangements (for example hyperchloremic acidosis and dilutional coagulopathy) and higher mortality as compared with LR Healey MA Davis RE Liu FC Loomis WH Hoyt DB Lactated ringers is superior to normal saline in a model of massive hemorrhage and resuscitation J Trauma 1998 45894-899 Todd SR Malinoski D Muller PJ Schreiber MA Lactated Ringers is superior to normal saline in the resuscitation of uncontrolled hemorrhagic shock J Trauma 2007 62636-639
Reported data from several studies conducted in critically ill patients have indicated that use of colloid solutions has a significant impact on hemorrhage hemostasis and inflammatory response Roberts I Alderson P Bunn F Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2004 CD000567 Vercueil A Grocott MP Mythen MG Physiology pharmacology and rationale for colloid administration for the maintenance of effective hemodynamic stability in critically ill patients Transfus Med Rev 2005 1993-109 Lee CC Chang IJ Yen ZS Effect of different resuscitation fluids on cytokine response in a rat model of hemorrhagic shock Shock 2005 24177-181
Early administration of blood is one potential treatment to decrease the
need for massive crystalloid solution in hemorrhagic shock however the
limited supply of stored blood and potential adverse effects make this
option logistically difficult and possibly harmful
West MA Sha piro MB Nathens AB Johnson JL Moore EE Minei JP Bankey PE Freeman B Harbrecht BG McKinley BA Moore FA Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core-standard operating procedures for clinical care IV Guidelines for transfusion in the trauma patient J Trauma 2006 61436-439
Moore FA McKinley BA Moore EE Nathens AB West M Shapiro MB Bankey P Freeman B Harbrecht BG Johnson JL Minei JP Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core standard operating procedures for clinical care III Guidelines for shock resuscitation J Trauma 2006 6182-89 Spahn DR Cerny V Coats TJ Duranteau J Fernandez-Mondejar E Gordini G Stahel PF Hunt BJ Komadina R Neugebauer E Ozier Y Riddez L Schultz A Vincent JL Rossaint R Task Force for Advanced Bleeding Care in Trauma Management of bleeding following major trauma a European guideline Crit Care 2007 11R17
Transfusion-related risks include possible development of MOF increased
ICU admissions and length of stay increased hospital length of stay and
mortality
Malone DL Dunne J Tracy JK Putnam AT Scalea TM Napolitano LM Blood transfusion independent of shock severity is associated with worse outcome in trauma J Trauma 2003 54898-905
Eastridge BJ Malone D Holcomb JB Early predictors of transfusion and mortality after injury a review of the data-based literature J Trauma 2006 60S20-S25
Napolitano L Cumulative risks of early red blood cell transfusion J Trauma 2006 60S26-S34
Cotton BA Guy JS Morris JA Jr Abumrad NN The cellular metabolic and systemic consequences of aggressive fluid resuscitation strategies Shock 2006 26115-121
uarr hemorrhage + excessive hemodilution due to
uarr Blood Presion darr blood viscosity darr hematocrit
darr clotting factor concentration
Risks of Aggressive Volume Resuscitation
rFVIIaThe use of rFVIIa was associated with improved early and late survival after severe trauma and massive transfusion
rFVIIa was not associated with increased risk of thrombotic events
The Effect of Recombinant Activated Factor VII on Mortality in Combat-Related Casualties With Severe Trauma and Massive Transfusion
bull Philip C Spinella MD Jeremy G Perkins MD Daniel F McLaughlin MD Sarah E Niles MD MPHKurt W Grathwohl MD Alec C Beekley MD Jose Salinas PhD Sumeru Mehta MD Charles E Wade PhDand John B Holcomb MD J of Trauma- Feb 2008bull Dutton et al J Trauma 200457709 Conclusion consider early use of FVIIa in any pt with uncontrolled hemorrhage who has not responded to surgery or blood component therapy
bull Each unit of blood product biologically active + elevates risk of infections + ARDS (SDRA)Chaiwat et al Anesthesiology 2009110351 n=14070 pts NSCOT database retrospective
bull Older blood association whith elevates infection LOS MOSF + death Weinberg et al J Trauma 200865279
TemperatureA temperature lt 96degF or 35degC is associated with an increase in mortality (cardiac arrest SRP higher abnormal plaquelet function) Burch J Denton J Noble R Physiologic rationale for abbreviated laparotomy Surg Clin North Am 1997 77779-82 Trauma patients that are hypothermic are NOT PERFUSING their tissue
The COAGULATION CASCADE is an enzymatic pathway that degrades with temperature and ceases at 92 FGregory JS Francbeum L Towsened MC Incidence and timing of hypothermia in trauma patients undergoing operations J Trauma 1991 31795-800 If the temperature is lower than 33 C the mortality is 100although Beilman and col think itacutes a significant factor for MODS but not for the mortalityBeilman GJ Blondet JJ Early hypothermia in severely injured trauma patients is a significant risk factor for multiple organ dysfunction syndrome but not mortality Ann Surg 2009 May249(5)845-50
Diagnosis done
Damage Control Resuscitation
1 Hypotensive resuscitation
2 Hemostatic resuscitation
Damage control philosophy can be extended to haemostatic resuscitation
Restoring normal coagulation Minimizing crystalloidTraditional resuscitation strategies dilute the already deficient coagulation factors and increase multiple organ failure
The aggressive hemostatic resuscitation should be combined with equally aggressive control of bleeding
Spahn DR Cerny V Management of bleeding following major trauma a European guidelineCrit Care 2007 11(1) R 17
WAIT AND SEE
SURGEON
ABDOMINAL PACKING is a lifesaving technique for temporary control of severe injury and it is used in damage control surgery schedule
Its possible too applying packs in organ-specific techniques (early abdominal packing)
The median survival of the 70 certainly superior to the obtainable survival with immediate surgical repairbullIMMEDIATE FAILURES are substantially due to bleeding especially in underpacking caseREMOTE FAILURES septic and bound at the time of stay (above the 72 hours) and associated by the coexistence of lesions in these situations is possible a MOF syndrome due to excessive intra-abdominal pressure (overpacking) or to an Abdominal Compartment Syndrome
Stagnitti F Bresadola L Calderale SM Coletti M Ribaldi S Salvi PF Schillaci F Abdominal packing indications and method Ann Ital Chir 2003 Sep-Oct74(5)535-42
Benavides C Garciacutea C Apablaza S Rubilar P Ricaurte F Perales C et al Empaquetamiento hepaacutetico permanente con malla de poliglactina en estallido hepaacutetico secundario a Siacutendrome de Hellp Rev Chil Cir 2004 56 275-278 De la Fuente M Mendoza VH Robledo-Oyarzun F Cierre Temporal de la pared abdominal con polietileno Cir Ciruj 2002 70157-63 Serna VH El Siacutendrome Compartamental Abdominal Tesis de Postgrado Meacutexico 2000
When skin approximation is
not possible a temporary silo
is constructed by suturing a 3-
L cystoscopy irrigation bag
(BOGOTAacute BAG) to the skin
edge with a continuous No 2
nylon suture
The method of closure depends on whether skin approximation produces excessive intra-abdominal hypertension
Towel-clip closure of the skin is preferred because it is quick and easy
The second phase is intra-operative reassessment for hemorrhage control 30 minutes after initial abdominal closure in the operating room focusing on restoration of the patients physiological status specifically reversing hypothermia and coagulopathy
WE CAN HEAR THE HEMORRHAGE
The abdomen is then reopened and assessed for adequacy of hemostasis and for existence of residual mechanical bleeding This practice has allowed surgeons to minimize both early return to the operating room for ongoing hemorrhage and the amount of packing necessary for hemostasis With bleeding effectively controlled the abdomen is reclosed
The patient is transferred to the ICU for continued physiologic restoration in the third phase
Once coagulopathy hypothermia and acidosis have been corrected the patient can be returned to the operating room for definitive management of the injuries in the fourth phase
48-72 h after first surgery
COMPLICATIONS OF DAMAGE CONTROL LAPAROTOMY
1) ACS Acute Compartmental Syndrome
2) ARDS Acute Respiratory Distress of the Adult
3) MOF Multiple organ failure
4) DEATH
ABDOMINAL COMPARTMENT SYNDROME is defined as an intra-abdominal pressure of greater than 20 cm H2O with evidence of impaired organ function ie elevated peak airway pressures (gt45 cm
H2O) oliguria (lt05 mLkg per hour) or cardiovascular dysfunction
(hypotension despite adequate volume resuscitation or if a pulmonary artery catheter is present oxygen delivery index [calculated as milliliters of oxygen per minute per meter squared] of 600) Intra-abdominal pressure was measured indirectly using an indwelling Foley catheter as previously described
Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13 Damage control surgery in the abdomen an approach for the management of severe injured patientsGermanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis NNuffield Department of Surgery John Radcliffe Hospital Oxford UK Curr Opin Crit Care 2006 Aug12(4)346-50 Damage-control laparotomy Lee JC Peitzman AB Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA
ABDOMINAL COMPARTMENT SYNDROME occurred in 17 (33) of
52 Patients undergoing damage-control laparotomy and was
associated with a much higher incidence of ARDS and MOF (71 vs
31 without ACS P = 02)
More importantly our study suggests that primary fascial closure at
the termination of the initial damage-control laparotomy contributes to
the development of ACS as well as subsequent organ failure
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal ypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
Mayberry JC Mullins RJ Crass RA Trunkey DD Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure Arch Surg 1997132957-962
bull MOF Multiple organ failure
Seems to be a major source of postinjury morbidity and the leading cause of in-hospital mortality despite more than 25 years of intense investigation
Eiseman B Beart R Norton L Multiple organ failure Surg Gynecol Obstet 1977144323-326
Bauer AE Durham R Faist E Systemic inflammatory response syndrome (SIRS) multiple organ dysfunction syndrome (MODS) multiple organ failure (MOF) are we winning the battle Shock 19981079-89
The current pathophysiologic model of MOF focuses on uncontrolled systemic
hyperinflammation as a unifying concept following a variety of insults
Moore FA Moore EE Evolving concepts in the pathogenesis of postinjury multiple organ failure Surg Clin North Am 199575257-277
Goris RJ te Boekhorst TP Nuytinck JK Gimbrere JS Multiple-organ failure generalized autodestructive inflammation Arch Surg 19851201109-1115
Nuytinck HK Offermans XJ Kubat K Goris JA Whole-body inflammation in trauma patients an autopsy study Arch Surg 19881231519-1524
Examples that improve the prognosis of MOF include damage control surgery recognition of abdominal compartment syndrome lung protective ventilation
strategies and tight glucose level control
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal hypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
The Acute Respiratory Distress Syndrome Network Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome N Engl J Med 20003421301-1308
Amato MB Barbas CS Medeiros DM et al Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome N Engl J Med 1998338347-354
Van den Berghe G Wouters P Weekers F et al Intensive insulin therapy in the critically ill patients N Engl J Med 20013451359-1367
The incidence of postinjury MOF has been reported to be between 7 and 66 with an associated mortality rate between 31 and 80
Fry DE Pearlstein L Fulton RL Polk HC Jr Multiple system organ failure the role of uncontrolled infection Arch Surg 1980115136-140
Regel G Lobenhoffer P Grotz M Pape HC Lehmann U Tscherne H Treatment results of patients with multiple trauma an analysis of 3406 cases treated between 1972 and 1991 at a German level I trauma center J Trauma 19953870-78
Sauaia A Moore FA Moore EE Norris JM Lezotte DC Hamman RF Multiple organ failure can be predicted as early as 12 hours after injury J Trauma 199845291-303
Nast-Kolb D Aufmkolk M Rucholtz S Obertacke U Waydhas C Multiple organ failure still a major cause of morbidity but not mortality in blunt multiple trauma J Trauma 200151835-842 Durham RM Moran JJ Mazuski JE Shapiro MJ Baue AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
It has been suggested that MOF is disappearing owing to advances in trauma and critical care
Levine JH Durham RM Moran J Bauer A Multiple organ failure is it disappearing World J Surg 199620471-473
Recent reports have not demonstrated a consistent change in either the incidence or the mortality rate associated with postinjury MOF Some groups have reported no change in the incidence but a decreased mortality while others have reported both decreased incidence and mortality compared with historical control subjects
Durham RM Moran JJ Mazuski JE Shapiro MJ Bauer AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
Regel G Grotz M Weltner T Sturm JA Tscherne H Pattern of organ failure following severe trauma World J Surg 199620422-429
Orthopaedic Trauma
Open pelvic fractures in addition to the pelvic ring injury are associated with hemorrhage and neurological insult visceral injuries are more common and a high rate of infection is seen Mortality of open pelvic fractures historically approached 50 Control of bleeding is the most important initial measure followed by debridement and packing of open wounds
Open book- widened symphysis pubis Dislocated Rt SI joint Vallier + Jenkins In Trauma Anesthesia 2008
Type 1 fractures occur due to anterior-posterior
compressioncan cause the symphysis pubis to ldquopoprdquo open leading to pubic rami or ldquoopen
bookrdquo fractures A lateral compression fracture type 2 or vertical sheer facture (Type 3) can
also lead to severe bleeding Into the pelvis Pelvic and acetabular surgery are major surgical interventions
Figura 1- Aplicacioacuten de la engrapadora para la reseccioacuten pulmonar en cuntildea Los segmentos a resecar se limitan por medio de la aplicacioacuten de dispositivos de grapado orientados en direcciones perpendiculares tratando de mantener la mayor cantidad de tejido sano
Insercioacuten de engrapadora lineal cortante a traveacutes de los orificios del tracto de la herida pulmonar penetrante
Figura 3- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales con fuga aeacuterea visible
Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales
Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
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-
bull In 1955 MADDING studied the temporal packing in hemorragic control after abdominal surgery
bull The MODERN era of damage-control laparotomy began with the seminal report of STONE ET AL from the Grady Memorial Hospital Atlanta Ga in 1982
Stone H Strom P Mullines R Management of the major coagulopathy with on set during laparotomy Ann Surg 1983 197532-535
bull The concept of damage control was introduced by ROTONDO y SCHWAB in patients with dangerous abdominal trauma described the three times in this surgery
Rotondo MF Mc Gonigol MD Schwab CW Kauder DR Hanson CW Damage Control An approach for improved survival in exsanguinating penetrating abdominal injury J Trauma 1993 35375-83
New Diagnostic criteriaAvoids the ldquobut he looked goodrdquo phenomenon
Within the first five minutes in the ED
Identify patients in trouble
Identify patients with increased mortality
Identify patients with increased probability of massive transfusion
The CONDUCT OF DAMAGE-CONTROL LAPAROTOMY has been described in detail elsewhere we can view the process in STAGES
Germanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis N Damage control surgery in the abdomen an approach for the management of severe injured patients Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13Lee JC Peitzman AB Nuffield Department of Surgery John Radcliffe Hospital Oxford UK Damage-control laparotomy Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA Curr Opin Crit Care 2006 Aug12(4)346-50
The MORE IMPORTANT PHASE is to IDENTIFY the appropriate candidate
bull Acidosis- Base Deficit gt - 6 phlt 72bull Coagulopathy INR gt 15 or TTPA gt 60 scbull Hypotension Systolic BP lt 90 mmHgbull Need of transfusion gt 4 l red cell contentsbull Temperature lt 96 5 F=34 Cbull Pattern recognition
bull Weak or absent radial pulse bull Abnormal mental statusbull Severe Traumatic Injury
DEATH
HYPOTHERMIA
ACIDOSIS
COAGULOPATHY
The Lethal TriadThe Lethal TriadThe Lethal TriadThe Lethal Triad
Soto S Oettinger R Brousse J Saacutenchez G Cirugiacutea de Control de Dantildeos Enfrentamiento actual del Trauma Cuad Cir 20031795-102
The OBJECTIVES are
1) STOP HEMORRHAGE to correct underlying coagulopathy
2) MINIMIZE PERITONEAL CONTAMINATION and its secondary inflammatory response
3) ENCLOSE THE ABDOMINAL CONTENTS to protect viscera and minimize protein loss
4) The final objective of this damage-control phase is CLOSURE OF THE ABDOMINAL CAVITY
bullRequires robust MEDICAL SETTING
bullNeed system approach to deliver casualties to MOST CAPABLE FACILITIES
bullIsolated and far forward facilities can still benefit from these principles
AcidosisAcidosisBASE DEFICIT (BD) ge -15 identifies patients that require early
transfusion increased ICU days and risk for ARDS and MOF Ferrara A Mac Arthur J Wright H Hypothermia and Acidosis worsen coagulopathy in the patient requiring massive transfusion Ann J Surg 1990 160515-518
bull BD of ge -15 is strongly associated with the need for massive transfusion and mortality in patients
Rutherford EJ Morris JA Reed GW Hall KS Base deficit stratifies mortality and determines therapy J Trauma 1992 33417-23
bull Patients have an elevated BD before their blood pressure drops to classic ldquohypotensionrdquo levels
bull Acidosis contributes more to coagulopathy more than hypothermia (not reversible)
bull An initial INR ge 15 reliably predicts those who will require massive transfusion
Moore FA Nelson T Massive transfusion in trauma patients tissue hemoglobin oxygen saturation predicts poor outcom J Trauma 2008 Apr 64 (4)1010-23
bull Patients who have a significant injury present with a coagulopathy
bull Severity of injury and mortality is linearly associated with the degree of the initial coagulopathy
Coagulopathy
bull Although resuscitation strategies for severely injured patients who present WITH SHOCK have improved greatly the transfusions are associated with development of MOF and increased intensive care unit (ICU) admissions ICU and hospital length of stay and mortality
bull Malone DL Dunne J Tracy JK Putnam AT Scalea TM Napolitano LM Blood
transfusion independent of shock severity is associated with worse outcome in trauma J Trauma 2003 54898-905
bull Eastridge BJ Malone D Holcomb JB Early predictors of transfusion and mortality
after injury a review of the data-based literature J Trauma 2006 60S20-S25 bull Napolitano L Cumulative risks of early red blood cell transfusion J Trauma 2006
60S26-S34 bull Cotton BA Guy JS Morris JA Jr Abumrad NN The cellular metabolic and systemic
consequences of aggressive fluid resuscitation strategies Shock 2006 26115-121
Current transfusion practices and survival rates of massive transfusion patients vary widely among trauma centers Conventional guidelines may underestimate the optimal plasma and platelet to RBC ratios
Survival in patients is associated with increased plasma and platelet ratios Massive transfusion practice guidelines should aim for a111 ratio of plasma plateletsRBCs bullHolcomb et al Ann Surg 2008248447
Kaplan-Meier survival plot for the first 24 hours after admission for the 4 groups (high plasma (FFPH) or platelet (PltH) to RBC ratio 12 low plasma (FFPL) or platelet (PltL) to RBC ratio 12)
Statistical modeling indicated that a
clinical guideline with mean plasma
RBC ratio equal to 11 would
encompass 98 of patients within
the optimal 12 ratio
Hypotension A systolic blood pressure of 90 mm Hg or less is indicative casualties that have lost over 40 of their blood volume
(~2000 ml in an adult)
They have impending cardiovascular collapse and have significantly increased mortality
The most efficient solution for use in resuscitation is still under debate
Lactated Ringers (LR) and normal isotonic saline solution (NS) remain the
most commonly used isotonic fluids
Although colloid solutions including hyperosmolar colloid and hypertonic
electrolyte compounds have been approved for use as volume expanders
their administration is still under debate in the USA and Europe
Moore FA McKinley BA Moore EE Nathens AB West M Shapiro MB Bankey P Freeman B Harbrecht BG Johnson JL Minei JP Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core standard operating procedures for clinical care III Guidelines for shock resuscitation J Trauma 2006 6182-89 Spahn DR Cerny V Coats TJ Duranteau J Fernandez-Mondejar E Gordini G Stahel PF Hunt BJ Komadina R Neugebauer E Ozier Y Riddez L Schultz A Vincent JL Rossaint R Task Force for Advanced Bleeding Care in Trauma Management of bleeding following major trauma a European guideline Crit Care 2007 11R17
Experimental studies have revealed that resuscitation with NS in the setting of massive hemorrhage requires significantly greater volume and is associated with increased physiologic derangements (for example hyperchloremic acidosis and dilutional coagulopathy) and higher mortality as compared with LR Healey MA Davis RE Liu FC Loomis WH Hoyt DB Lactated ringers is superior to normal saline in a model of massive hemorrhage and resuscitation J Trauma 1998 45894-899 Todd SR Malinoski D Muller PJ Schreiber MA Lactated Ringers is superior to normal saline in the resuscitation of uncontrolled hemorrhagic shock J Trauma 2007 62636-639
Reported data from several studies conducted in critically ill patients have indicated that use of colloid solutions has a significant impact on hemorrhage hemostasis and inflammatory response Roberts I Alderson P Bunn F Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2004 CD000567 Vercueil A Grocott MP Mythen MG Physiology pharmacology and rationale for colloid administration for the maintenance of effective hemodynamic stability in critically ill patients Transfus Med Rev 2005 1993-109 Lee CC Chang IJ Yen ZS Effect of different resuscitation fluids on cytokine response in a rat model of hemorrhagic shock Shock 2005 24177-181
Early administration of blood is one potential treatment to decrease the
need for massive crystalloid solution in hemorrhagic shock however the
limited supply of stored blood and potential adverse effects make this
option logistically difficult and possibly harmful
West MA Sha piro MB Nathens AB Johnson JL Moore EE Minei JP Bankey PE Freeman B Harbrecht BG McKinley BA Moore FA Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core-standard operating procedures for clinical care IV Guidelines for transfusion in the trauma patient J Trauma 2006 61436-439
Moore FA McKinley BA Moore EE Nathens AB West M Shapiro MB Bankey P Freeman B Harbrecht BG Johnson JL Minei JP Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core standard operating procedures for clinical care III Guidelines for shock resuscitation J Trauma 2006 6182-89 Spahn DR Cerny V Coats TJ Duranteau J Fernandez-Mondejar E Gordini G Stahel PF Hunt BJ Komadina R Neugebauer E Ozier Y Riddez L Schultz A Vincent JL Rossaint R Task Force for Advanced Bleeding Care in Trauma Management of bleeding following major trauma a European guideline Crit Care 2007 11R17
Transfusion-related risks include possible development of MOF increased
ICU admissions and length of stay increased hospital length of stay and
mortality
Malone DL Dunne J Tracy JK Putnam AT Scalea TM Napolitano LM Blood transfusion independent of shock severity is associated with worse outcome in trauma J Trauma 2003 54898-905
Eastridge BJ Malone D Holcomb JB Early predictors of transfusion and mortality after injury a review of the data-based literature J Trauma 2006 60S20-S25
Napolitano L Cumulative risks of early red blood cell transfusion J Trauma 2006 60S26-S34
Cotton BA Guy JS Morris JA Jr Abumrad NN The cellular metabolic and systemic consequences of aggressive fluid resuscitation strategies Shock 2006 26115-121
uarr hemorrhage + excessive hemodilution due to
uarr Blood Presion darr blood viscosity darr hematocrit
darr clotting factor concentration
Risks of Aggressive Volume Resuscitation
rFVIIaThe use of rFVIIa was associated with improved early and late survival after severe trauma and massive transfusion
rFVIIa was not associated with increased risk of thrombotic events
The Effect of Recombinant Activated Factor VII on Mortality in Combat-Related Casualties With Severe Trauma and Massive Transfusion
bull Philip C Spinella MD Jeremy G Perkins MD Daniel F McLaughlin MD Sarah E Niles MD MPHKurt W Grathwohl MD Alec C Beekley MD Jose Salinas PhD Sumeru Mehta MD Charles E Wade PhDand John B Holcomb MD J of Trauma- Feb 2008bull Dutton et al J Trauma 200457709 Conclusion consider early use of FVIIa in any pt with uncontrolled hemorrhage who has not responded to surgery or blood component therapy
bull Each unit of blood product biologically active + elevates risk of infections + ARDS (SDRA)Chaiwat et al Anesthesiology 2009110351 n=14070 pts NSCOT database retrospective
bull Older blood association whith elevates infection LOS MOSF + death Weinberg et al J Trauma 200865279
TemperatureA temperature lt 96degF or 35degC is associated with an increase in mortality (cardiac arrest SRP higher abnormal plaquelet function) Burch J Denton J Noble R Physiologic rationale for abbreviated laparotomy Surg Clin North Am 1997 77779-82 Trauma patients that are hypothermic are NOT PERFUSING their tissue
The COAGULATION CASCADE is an enzymatic pathway that degrades with temperature and ceases at 92 FGregory JS Francbeum L Towsened MC Incidence and timing of hypothermia in trauma patients undergoing operations J Trauma 1991 31795-800 If the temperature is lower than 33 C the mortality is 100although Beilman and col think itacutes a significant factor for MODS but not for the mortalityBeilman GJ Blondet JJ Early hypothermia in severely injured trauma patients is a significant risk factor for multiple organ dysfunction syndrome but not mortality Ann Surg 2009 May249(5)845-50
Diagnosis done
Damage Control Resuscitation
1 Hypotensive resuscitation
2 Hemostatic resuscitation
Damage control philosophy can be extended to haemostatic resuscitation
Restoring normal coagulation Minimizing crystalloidTraditional resuscitation strategies dilute the already deficient coagulation factors and increase multiple organ failure
The aggressive hemostatic resuscitation should be combined with equally aggressive control of bleeding
Spahn DR Cerny V Management of bleeding following major trauma a European guidelineCrit Care 2007 11(1) R 17
WAIT AND SEE
SURGEON
ABDOMINAL PACKING is a lifesaving technique for temporary control of severe injury and it is used in damage control surgery schedule
Its possible too applying packs in organ-specific techniques (early abdominal packing)
The median survival of the 70 certainly superior to the obtainable survival with immediate surgical repairbullIMMEDIATE FAILURES are substantially due to bleeding especially in underpacking caseREMOTE FAILURES septic and bound at the time of stay (above the 72 hours) and associated by the coexistence of lesions in these situations is possible a MOF syndrome due to excessive intra-abdominal pressure (overpacking) or to an Abdominal Compartment Syndrome
Stagnitti F Bresadola L Calderale SM Coletti M Ribaldi S Salvi PF Schillaci F Abdominal packing indications and method Ann Ital Chir 2003 Sep-Oct74(5)535-42
Benavides C Garciacutea C Apablaza S Rubilar P Ricaurte F Perales C et al Empaquetamiento hepaacutetico permanente con malla de poliglactina en estallido hepaacutetico secundario a Siacutendrome de Hellp Rev Chil Cir 2004 56 275-278 De la Fuente M Mendoza VH Robledo-Oyarzun F Cierre Temporal de la pared abdominal con polietileno Cir Ciruj 2002 70157-63 Serna VH El Siacutendrome Compartamental Abdominal Tesis de Postgrado Meacutexico 2000
When skin approximation is
not possible a temporary silo
is constructed by suturing a 3-
L cystoscopy irrigation bag
(BOGOTAacute BAG) to the skin
edge with a continuous No 2
nylon suture
The method of closure depends on whether skin approximation produces excessive intra-abdominal hypertension
Towel-clip closure of the skin is preferred because it is quick and easy
The second phase is intra-operative reassessment for hemorrhage control 30 minutes after initial abdominal closure in the operating room focusing on restoration of the patients physiological status specifically reversing hypothermia and coagulopathy
WE CAN HEAR THE HEMORRHAGE
The abdomen is then reopened and assessed for adequacy of hemostasis and for existence of residual mechanical bleeding This practice has allowed surgeons to minimize both early return to the operating room for ongoing hemorrhage and the amount of packing necessary for hemostasis With bleeding effectively controlled the abdomen is reclosed
The patient is transferred to the ICU for continued physiologic restoration in the third phase
Once coagulopathy hypothermia and acidosis have been corrected the patient can be returned to the operating room for definitive management of the injuries in the fourth phase
48-72 h after first surgery
COMPLICATIONS OF DAMAGE CONTROL LAPAROTOMY
1) ACS Acute Compartmental Syndrome
2) ARDS Acute Respiratory Distress of the Adult
3) MOF Multiple organ failure
4) DEATH
ABDOMINAL COMPARTMENT SYNDROME is defined as an intra-abdominal pressure of greater than 20 cm H2O with evidence of impaired organ function ie elevated peak airway pressures (gt45 cm
H2O) oliguria (lt05 mLkg per hour) or cardiovascular dysfunction
(hypotension despite adequate volume resuscitation or if a pulmonary artery catheter is present oxygen delivery index [calculated as milliliters of oxygen per minute per meter squared] of 600) Intra-abdominal pressure was measured indirectly using an indwelling Foley catheter as previously described
Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13 Damage control surgery in the abdomen an approach for the management of severe injured patientsGermanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis NNuffield Department of Surgery John Radcliffe Hospital Oxford UK Curr Opin Crit Care 2006 Aug12(4)346-50 Damage-control laparotomy Lee JC Peitzman AB Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA
ABDOMINAL COMPARTMENT SYNDROME occurred in 17 (33) of
52 Patients undergoing damage-control laparotomy and was
associated with a much higher incidence of ARDS and MOF (71 vs
31 without ACS P = 02)
More importantly our study suggests that primary fascial closure at
the termination of the initial damage-control laparotomy contributes to
the development of ACS as well as subsequent organ failure
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal ypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
Mayberry JC Mullins RJ Crass RA Trunkey DD Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure Arch Surg 1997132957-962
bull MOF Multiple organ failure
Seems to be a major source of postinjury morbidity and the leading cause of in-hospital mortality despite more than 25 years of intense investigation
Eiseman B Beart R Norton L Multiple organ failure Surg Gynecol Obstet 1977144323-326
Bauer AE Durham R Faist E Systemic inflammatory response syndrome (SIRS) multiple organ dysfunction syndrome (MODS) multiple organ failure (MOF) are we winning the battle Shock 19981079-89
The current pathophysiologic model of MOF focuses on uncontrolled systemic
hyperinflammation as a unifying concept following a variety of insults
Moore FA Moore EE Evolving concepts in the pathogenesis of postinjury multiple organ failure Surg Clin North Am 199575257-277
Goris RJ te Boekhorst TP Nuytinck JK Gimbrere JS Multiple-organ failure generalized autodestructive inflammation Arch Surg 19851201109-1115
Nuytinck HK Offermans XJ Kubat K Goris JA Whole-body inflammation in trauma patients an autopsy study Arch Surg 19881231519-1524
Examples that improve the prognosis of MOF include damage control surgery recognition of abdominal compartment syndrome lung protective ventilation
strategies and tight glucose level control
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal hypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
The Acute Respiratory Distress Syndrome Network Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome N Engl J Med 20003421301-1308
Amato MB Barbas CS Medeiros DM et al Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome N Engl J Med 1998338347-354
Van den Berghe G Wouters P Weekers F et al Intensive insulin therapy in the critically ill patients N Engl J Med 20013451359-1367
The incidence of postinjury MOF has been reported to be between 7 and 66 with an associated mortality rate between 31 and 80
Fry DE Pearlstein L Fulton RL Polk HC Jr Multiple system organ failure the role of uncontrolled infection Arch Surg 1980115136-140
Regel G Lobenhoffer P Grotz M Pape HC Lehmann U Tscherne H Treatment results of patients with multiple trauma an analysis of 3406 cases treated between 1972 and 1991 at a German level I trauma center J Trauma 19953870-78
Sauaia A Moore FA Moore EE Norris JM Lezotte DC Hamman RF Multiple organ failure can be predicted as early as 12 hours after injury J Trauma 199845291-303
Nast-Kolb D Aufmkolk M Rucholtz S Obertacke U Waydhas C Multiple organ failure still a major cause of morbidity but not mortality in blunt multiple trauma J Trauma 200151835-842 Durham RM Moran JJ Mazuski JE Shapiro MJ Baue AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
It has been suggested that MOF is disappearing owing to advances in trauma and critical care
Levine JH Durham RM Moran J Bauer A Multiple organ failure is it disappearing World J Surg 199620471-473
Recent reports have not demonstrated a consistent change in either the incidence or the mortality rate associated with postinjury MOF Some groups have reported no change in the incidence but a decreased mortality while others have reported both decreased incidence and mortality compared with historical control subjects
Durham RM Moran JJ Mazuski JE Shapiro MJ Bauer AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
Regel G Grotz M Weltner T Sturm JA Tscherne H Pattern of organ failure following severe trauma World J Surg 199620422-429
Orthopaedic Trauma
Open pelvic fractures in addition to the pelvic ring injury are associated with hemorrhage and neurological insult visceral injuries are more common and a high rate of infection is seen Mortality of open pelvic fractures historically approached 50 Control of bleeding is the most important initial measure followed by debridement and packing of open wounds
Open book- widened symphysis pubis Dislocated Rt SI joint Vallier + Jenkins In Trauma Anesthesia 2008
Type 1 fractures occur due to anterior-posterior
compressioncan cause the symphysis pubis to ldquopoprdquo open leading to pubic rami or ldquoopen
bookrdquo fractures A lateral compression fracture type 2 or vertical sheer facture (Type 3) can
also lead to severe bleeding Into the pelvis Pelvic and acetabular surgery are major surgical interventions
Figura 1- Aplicacioacuten de la engrapadora para la reseccioacuten pulmonar en cuntildea Los segmentos a resecar se limitan por medio de la aplicacioacuten de dispositivos de grapado orientados en direcciones perpendiculares tratando de mantener la mayor cantidad de tejido sano
Insercioacuten de engrapadora lineal cortante a traveacutes de los orificios del tracto de la herida pulmonar penetrante
Figura 3- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales con fuga aeacuterea visible
Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales
Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
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-
New Diagnostic criteriaAvoids the ldquobut he looked goodrdquo phenomenon
Within the first five minutes in the ED
Identify patients in trouble
Identify patients with increased mortality
Identify patients with increased probability of massive transfusion
The CONDUCT OF DAMAGE-CONTROL LAPAROTOMY has been described in detail elsewhere we can view the process in STAGES
Germanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis N Damage control surgery in the abdomen an approach for the management of severe injured patients Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13Lee JC Peitzman AB Nuffield Department of Surgery John Radcliffe Hospital Oxford UK Damage-control laparotomy Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA Curr Opin Crit Care 2006 Aug12(4)346-50
The MORE IMPORTANT PHASE is to IDENTIFY the appropriate candidate
bull Acidosis- Base Deficit gt - 6 phlt 72bull Coagulopathy INR gt 15 or TTPA gt 60 scbull Hypotension Systolic BP lt 90 mmHgbull Need of transfusion gt 4 l red cell contentsbull Temperature lt 96 5 F=34 Cbull Pattern recognition
bull Weak or absent radial pulse bull Abnormal mental statusbull Severe Traumatic Injury
DEATH
HYPOTHERMIA
ACIDOSIS
COAGULOPATHY
The Lethal TriadThe Lethal TriadThe Lethal TriadThe Lethal Triad
Soto S Oettinger R Brousse J Saacutenchez G Cirugiacutea de Control de Dantildeos Enfrentamiento actual del Trauma Cuad Cir 20031795-102
The OBJECTIVES are
1) STOP HEMORRHAGE to correct underlying coagulopathy
2) MINIMIZE PERITONEAL CONTAMINATION and its secondary inflammatory response
3) ENCLOSE THE ABDOMINAL CONTENTS to protect viscera and minimize protein loss
4) The final objective of this damage-control phase is CLOSURE OF THE ABDOMINAL CAVITY
bullRequires robust MEDICAL SETTING
bullNeed system approach to deliver casualties to MOST CAPABLE FACILITIES
bullIsolated and far forward facilities can still benefit from these principles
AcidosisAcidosisBASE DEFICIT (BD) ge -15 identifies patients that require early
transfusion increased ICU days and risk for ARDS and MOF Ferrara A Mac Arthur J Wright H Hypothermia and Acidosis worsen coagulopathy in the patient requiring massive transfusion Ann J Surg 1990 160515-518
bull BD of ge -15 is strongly associated with the need for massive transfusion and mortality in patients
Rutherford EJ Morris JA Reed GW Hall KS Base deficit stratifies mortality and determines therapy J Trauma 1992 33417-23
bull Patients have an elevated BD before their blood pressure drops to classic ldquohypotensionrdquo levels
bull Acidosis contributes more to coagulopathy more than hypothermia (not reversible)
bull An initial INR ge 15 reliably predicts those who will require massive transfusion
Moore FA Nelson T Massive transfusion in trauma patients tissue hemoglobin oxygen saturation predicts poor outcom J Trauma 2008 Apr 64 (4)1010-23
bull Patients who have a significant injury present with a coagulopathy
bull Severity of injury and mortality is linearly associated with the degree of the initial coagulopathy
Coagulopathy
bull Although resuscitation strategies for severely injured patients who present WITH SHOCK have improved greatly the transfusions are associated with development of MOF and increased intensive care unit (ICU) admissions ICU and hospital length of stay and mortality
bull Malone DL Dunne J Tracy JK Putnam AT Scalea TM Napolitano LM Blood
transfusion independent of shock severity is associated with worse outcome in trauma J Trauma 2003 54898-905
bull Eastridge BJ Malone D Holcomb JB Early predictors of transfusion and mortality
after injury a review of the data-based literature J Trauma 2006 60S20-S25 bull Napolitano L Cumulative risks of early red blood cell transfusion J Trauma 2006
60S26-S34 bull Cotton BA Guy JS Morris JA Jr Abumrad NN The cellular metabolic and systemic
consequences of aggressive fluid resuscitation strategies Shock 2006 26115-121
Current transfusion practices and survival rates of massive transfusion patients vary widely among trauma centers Conventional guidelines may underestimate the optimal plasma and platelet to RBC ratios
Survival in patients is associated with increased plasma and platelet ratios Massive transfusion practice guidelines should aim for a111 ratio of plasma plateletsRBCs bullHolcomb et al Ann Surg 2008248447
Kaplan-Meier survival plot for the first 24 hours after admission for the 4 groups (high plasma (FFPH) or platelet (PltH) to RBC ratio 12 low plasma (FFPL) or platelet (PltL) to RBC ratio 12)
Statistical modeling indicated that a
clinical guideline with mean plasma
RBC ratio equal to 11 would
encompass 98 of patients within
the optimal 12 ratio
Hypotension A systolic blood pressure of 90 mm Hg or less is indicative casualties that have lost over 40 of their blood volume
(~2000 ml in an adult)
They have impending cardiovascular collapse and have significantly increased mortality
The most efficient solution for use in resuscitation is still under debate
Lactated Ringers (LR) and normal isotonic saline solution (NS) remain the
most commonly used isotonic fluids
Although colloid solutions including hyperosmolar colloid and hypertonic
electrolyte compounds have been approved for use as volume expanders
their administration is still under debate in the USA and Europe
Moore FA McKinley BA Moore EE Nathens AB West M Shapiro MB Bankey P Freeman B Harbrecht BG Johnson JL Minei JP Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core standard operating procedures for clinical care III Guidelines for shock resuscitation J Trauma 2006 6182-89 Spahn DR Cerny V Coats TJ Duranteau J Fernandez-Mondejar E Gordini G Stahel PF Hunt BJ Komadina R Neugebauer E Ozier Y Riddez L Schultz A Vincent JL Rossaint R Task Force for Advanced Bleeding Care in Trauma Management of bleeding following major trauma a European guideline Crit Care 2007 11R17
Experimental studies have revealed that resuscitation with NS in the setting of massive hemorrhage requires significantly greater volume and is associated with increased physiologic derangements (for example hyperchloremic acidosis and dilutional coagulopathy) and higher mortality as compared with LR Healey MA Davis RE Liu FC Loomis WH Hoyt DB Lactated ringers is superior to normal saline in a model of massive hemorrhage and resuscitation J Trauma 1998 45894-899 Todd SR Malinoski D Muller PJ Schreiber MA Lactated Ringers is superior to normal saline in the resuscitation of uncontrolled hemorrhagic shock J Trauma 2007 62636-639
Reported data from several studies conducted in critically ill patients have indicated that use of colloid solutions has a significant impact on hemorrhage hemostasis and inflammatory response Roberts I Alderson P Bunn F Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2004 CD000567 Vercueil A Grocott MP Mythen MG Physiology pharmacology and rationale for colloid administration for the maintenance of effective hemodynamic stability in critically ill patients Transfus Med Rev 2005 1993-109 Lee CC Chang IJ Yen ZS Effect of different resuscitation fluids on cytokine response in a rat model of hemorrhagic shock Shock 2005 24177-181
Early administration of blood is one potential treatment to decrease the
need for massive crystalloid solution in hemorrhagic shock however the
limited supply of stored blood and potential adverse effects make this
option logistically difficult and possibly harmful
West MA Sha piro MB Nathens AB Johnson JL Moore EE Minei JP Bankey PE Freeman B Harbrecht BG McKinley BA Moore FA Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core-standard operating procedures for clinical care IV Guidelines for transfusion in the trauma patient J Trauma 2006 61436-439
Moore FA McKinley BA Moore EE Nathens AB West M Shapiro MB Bankey P Freeman B Harbrecht BG Johnson JL Minei JP Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core standard operating procedures for clinical care III Guidelines for shock resuscitation J Trauma 2006 6182-89 Spahn DR Cerny V Coats TJ Duranteau J Fernandez-Mondejar E Gordini G Stahel PF Hunt BJ Komadina R Neugebauer E Ozier Y Riddez L Schultz A Vincent JL Rossaint R Task Force for Advanced Bleeding Care in Trauma Management of bleeding following major trauma a European guideline Crit Care 2007 11R17
Transfusion-related risks include possible development of MOF increased
ICU admissions and length of stay increased hospital length of stay and
mortality
Malone DL Dunne J Tracy JK Putnam AT Scalea TM Napolitano LM Blood transfusion independent of shock severity is associated with worse outcome in trauma J Trauma 2003 54898-905
Eastridge BJ Malone D Holcomb JB Early predictors of transfusion and mortality after injury a review of the data-based literature J Trauma 2006 60S20-S25
Napolitano L Cumulative risks of early red blood cell transfusion J Trauma 2006 60S26-S34
Cotton BA Guy JS Morris JA Jr Abumrad NN The cellular metabolic and systemic consequences of aggressive fluid resuscitation strategies Shock 2006 26115-121
uarr hemorrhage + excessive hemodilution due to
uarr Blood Presion darr blood viscosity darr hematocrit
darr clotting factor concentration
Risks of Aggressive Volume Resuscitation
rFVIIaThe use of rFVIIa was associated with improved early and late survival after severe trauma and massive transfusion
rFVIIa was not associated with increased risk of thrombotic events
The Effect of Recombinant Activated Factor VII on Mortality in Combat-Related Casualties With Severe Trauma and Massive Transfusion
bull Philip C Spinella MD Jeremy G Perkins MD Daniel F McLaughlin MD Sarah E Niles MD MPHKurt W Grathwohl MD Alec C Beekley MD Jose Salinas PhD Sumeru Mehta MD Charles E Wade PhDand John B Holcomb MD J of Trauma- Feb 2008bull Dutton et al J Trauma 200457709 Conclusion consider early use of FVIIa in any pt with uncontrolled hemorrhage who has not responded to surgery or blood component therapy
bull Each unit of blood product biologically active + elevates risk of infections + ARDS (SDRA)Chaiwat et al Anesthesiology 2009110351 n=14070 pts NSCOT database retrospective
bull Older blood association whith elevates infection LOS MOSF + death Weinberg et al J Trauma 200865279
TemperatureA temperature lt 96degF or 35degC is associated with an increase in mortality (cardiac arrest SRP higher abnormal plaquelet function) Burch J Denton J Noble R Physiologic rationale for abbreviated laparotomy Surg Clin North Am 1997 77779-82 Trauma patients that are hypothermic are NOT PERFUSING their tissue
The COAGULATION CASCADE is an enzymatic pathway that degrades with temperature and ceases at 92 FGregory JS Francbeum L Towsened MC Incidence and timing of hypothermia in trauma patients undergoing operations J Trauma 1991 31795-800 If the temperature is lower than 33 C the mortality is 100although Beilman and col think itacutes a significant factor for MODS but not for the mortalityBeilman GJ Blondet JJ Early hypothermia in severely injured trauma patients is a significant risk factor for multiple organ dysfunction syndrome but not mortality Ann Surg 2009 May249(5)845-50
Diagnosis done
Damage Control Resuscitation
1 Hypotensive resuscitation
2 Hemostatic resuscitation
Damage control philosophy can be extended to haemostatic resuscitation
Restoring normal coagulation Minimizing crystalloidTraditional resuscitation strategies dilute the already deficient coagulation factors and increase multiple organ failure
The aggressive hemostatic resuscitation should be combined with equally aggressive control of bleeding
Spahn DR Cerny V Management of bleeding following major trauma a European guidelineCrit Care 2007 11(1) R 17
WAIT AND SEE
SURGEON
ABDOMINAL PACKING is a lifesaving technique for temporary control of severe injury and it is used in damage control surgery schedule
Its possible too applying packs in organ-specific techniques (early abdominal packing)
The median survival of the 70 certainly superior to the obtainable survival with immediate surgical repairbullIMMEDIATE FAILURES are substantially due to bleeding especially in underpacking caseREMOTE FAILURES septic and bound at the time of stay (above the 72 hours) and associated by the coexistence of lesions in these situations is possible a MOF syndrome due to excessive intra-abdominal pressure (overpacking) or to an Abdominal Compartment Syndrome
Stagnitti F Bresadola L Calderale SM Coletti M Ribaldi S Salvi PF Schillaci F Abdominal packing indications and method Ann Ital Chir 2003 Sep-Oct74(5)535-42
Benavides C Garciacutea C Apablaza S Rubilar P Ricaurte F Perales C et al Empaquetamiento hepaacutetico permanente con malla de poliglactina en estallido hepaacutetico secundario a Siacutendrome de Hellp Rev Chil Cir 2004 56 275-278 De la Fuente M Mendoza VH Robledo-Oyarzun F Cierre Temporal de la pared abdominal con polietileno Cir Ciruj 2002 70157-63 Serna VH El Siacutendrome Compartamental Abdominal Tesis de Postgrado Meacutexico 2000
When skin approximation is
not possible a temporary silo
is constructed by suturing a 3-
L cystoscopy irrigation bag
(BOGOTAacute BAG) to the skin
edge with a continuous No 2
nylon suture
The method of closure depends on whether skin approximation produces excessive intra-abdominal hypertension
Towel-clip closure of the skin is preferred because it is quick and easy
The second phase is intra-operative reassessment for hemorrhage control 30 minutes after initial abdominal closure in the operating room focusing on restoration of the patients physiological status specifically reversing hypothermia and coagulopathy
WE CAN HEAR THE HEMORRHAGE
The abdomen is then reopened and assessed for adequacy of hemostasis and for existence of residual mechanical bleeding This practice has allowed surgeons to minimize both early return to the operating room for ongoing hemorrhage and the amount of packing necessary for hemostasis With bleeding effectively controlled the abdomen is reclosed
The patient is transferred to the ICU for continued physiologic restoration in the third phase
Once coagulopathy hypothermia and acidosis have been corrected the patient can be returned to the operating room for definitive management of the injuries in the fourth phase
48-72 h after first surgery
COMPLICATIONS OF DAMAGE CONTROL LAPAROTOMY
1) ACS Acute Compartmental Syndrome
2) ARDS Acute Respiratory Distress of the Adult
3) MOF Multiple organ failure
4) DEATH
ABDOMINAL COMPARTMENT SYNDROME is defined as an intra-abdominal pressure of greater than 20 cm H2O with evidence of impaired organ function ie elevated peak airway pressures (gt45 cm
H2O) oliguria (lt05 mLkg per hour) or cardiovascular dysfunction
(hypotension despite adequate volume resuscitation or if a pulmonary artery catheter is present oxygen delivery index [calculated as milliliters of oxygen per minute per meter squared] of 600) Intra-abdominal pressure was measured indirectly using an indwelling Foley catheter as previously described
Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13 Damage control surgery in the abdomen an approach for the management of severe injured patientsGermanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis NNuffield Department of Surgery John Radcliffe Hospital Oxford UK Curr Opin Crit Care 2006 Aug12(4)346-50 Damage-control laparotomy Lee JC Peitzman AB Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA
ABDOMINAL COMPARTMENT SYNDROME occurred in 17 (33) of
52 Patients undergoing damage-control laparotomy and was
associated with a much higher incidence of ARDS and MOF (71 vs
31 without ACS P = 02)
More importantly our study suggests that primary fascial closure at
the termination of the initial damage-control laparotomy contributes to
the development of ACS as well as subsequent organ failure
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal ypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
Mayberry JC Mullins RJ Crass RA Trunkey DD Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure Arch Surg 1997132957-962
bull MOF Multiple organ failure
Seems to be a major source of postinjury morbidity and the leading cause of in-hospital mortality despite more than 25 years of intense investigation
Eiseman B Beart R Norton L Multiple organ failure Surg Gynecol Obstet 1977144323-326
Bauer AE Durham R Faist E Systemic inflammatory response syndrome (SIRS) multiple organ dysfunction syndrome (MODS) multiple organ failure (MOF) are we winning the battle Shock 19981079-89
The current pathophysiologic model of MOF focuses on uncontrolled systemic
hyperinflammation as a unifying concept following a variety of insults
Moore FA Moore EE Evolving concepts in the pathogenesis of postinjury multiple organ failure Surg Clin North Am 199575257-277
Goris RJ te Boekhorst TP Nuytinck JK Gimbrere JS Multiple-organ failure generalized autodestructive inflammation Arch Surg 19851201109-1115
Nuytinck HK Offermans XJ Kubat K Goris JA Whole-body inflammation in trauma patients an autopsy study Arch Surg 19881231519-1524
Examples that improve the prognosis of MOF include damage control surgery recognition of abdominal compartment syndrome lung protective ventilation
strategies and tight glucose level control
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal hypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
The Acute Respiratory Distress Syndrome Network Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome N Engl J Med 20003421301-1308
Amato MB Barbas CS Medeiros DM et al Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome N Engl J Med 1998338347-354
Van den Berghe G Wouters P Weekers F et al Intensive insulin therapy in the critically ill patients N Engl J Med 20013451359-1367
The incidence of postinjury MOF has been reported to be between 7 and 66 with an associated mortality rate between 31 and 80
Fry DE Pearlstein L Fulton RL Polk HC Jr Multiple system organ failure the role of uncontrolled infection Arch Surg 1980115136-140
Regel G Lobenhoffer P Grotz M Pape HC Lehmann U Tscherne H Treatment results of patients with multiple trauma an analysis of 3406 cases treated between 1972 and 1991 at a German level I trauma center J Trauma 19953870-78
Sauaia A Moore FA Moore EE Norris JM Lezotte DC Hamman RF Multiple organ failure can be predicted as early as 12 hours after injury J Trauma 199845291-303
Nast-Kolb D Aufmkolk M Rucholtz S Obertacke U Waydhas C Multiple organ failure still a major cause of morbidity but not mortality in blunt multiple trauma J Trauma 200151835-842 Durham RM Moran JJ Mazuski JE Shapiro MJ Baue AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
It has been suggested that MOF is disappearing owing to advances in trauma and critical care
Levine JH Durham RM Moran J Bauer A Multiple organ failure is it disappearing World J Surg 199620471-473
Recent reports have not demonstrated a consistent change in either the incidence or the mortality rate associated with postinjury MOF Some groups have reported no change in the incidence but a decreased mortality while others have reported both decreased incidence and mortality compared with historical control subjects
Durham RM Moran JJ Mazuski JE Shapiro MJ Bauer AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
Regel G Grotz M Weltner T Sturm JA Tscherne H Pattern of organ failure following severe trauma World J Surg 199620422-429
Orthopaedic Trauma
Open pelvic fractures in addition to the pelvic ring injury are associated with hemorrhage and neurological insult visceral injuries are more common and a high rate of infection is seen Mortality of open pelvic fractures historically approached 50 Control of bleeding is the most important initial measure followed by debridement and packing of open wounds
Open book- widened symphysis pubis Dislocated Rt SI joint Vallier + Jenkins In Trauma Anesthesia 2008
Type 1 fractures occur due to anterior-posterior
compressioncan cause the symphysis pubis to ldquopoprdquo open leading to pubic rami or ldquoopen
bookrdquo fractures A lateral compression fracture type 2 or vertical sheer facture (Type 3) can
also lead to severe bleeding Into the pelvis Pelvic and acetabular surgery are major surgical interventions
Figura 1- Aplicacioacuten de la engrapadora para la reseccioacuten pulmonar en cuntildea Los segmentos a resecar se limitan por medio de la aplicacioacuten de dispositivos de grapado orientados en direcciones perpendiculares tratando de mantener la mayor cantidad de tejido sano
Insercioacuten de engrapadora lineal cortante a traveacutes de los orificios del tracto de la herida pulmonar penetrante
Figura 3- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales con fuga aeacuterea visible
Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales
Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
- Slide 1
- Slide 2
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
- Slide 10
- Slide 11
- Slide 12
- Slide 13
- Slide 14
- Slide 15
- Slide 16
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- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- Slide 31
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Slide 36
- Slide 37
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
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- Slide 57
- Slide 58
- Slide 59
-
The CONDUCT OF DAMAGE-CONTROL LAPAROTOMY has been described in detail elsewhere we can view the process in STAGES
Germanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis N Damage control surgery in the abdomen an approach for the management of severe injured patients Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13Lee JC Peitzman AB Nuffield Department of Surgery John Radcliffe Hospital Oxford UK Damage-control laparotomy Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA Curr Opin Crit Care 2006 Aug12(4)346-50
The MORE IMPORTANT PHASE is to IDENTIFY the appropriate candidate
bull Acidosis- Base Deficit gt - 6 phlt 72bull Coagulopathy INR gt 15 or TTPA gt 60 scbull Hypotension Systolic BP lt 90 mmHgbull Need of transfusion gt 4 l red cell contentsbull Temperature lt 96 5 F=34 Cbull Pattern recognition
bull Weak or absent radial pulse bull Abnormal mental statusbull Severe Traumatic Injury
DEATH
HYPOTHERMIA
ACIDOSIS
COAGULOPATHY
The Lethal TriadThe Lethal TriadThe Lethal TriadThe Lethal Triad
Soto S Oettinger R Brousse J Saacutenchez G Cirugiacutea de Control de Dantildeos Enfrentamiento actual del Trauma Cuad Cir 20031795-102
The OBJECTIVES are
1) STOP HEMORRHAGE to correct underlying coagulopathy
2) MINIMIZE PERITONEAL CONTAMINATION and its secondary inflammatory response
3) ENCLOSE THE ABDOMINAL CONTENTS to protect viscera and minimize protein loss
4) The final objective of this damage-control phase is CLOSURE OF THE ABDOMINAL CAVITY
bullRequires robust MEDICAL SETTING
bullNeed system approach to deliver casualties to MOST CAPABLE FACILITIES
bullIsolated and far forward facilities can still benefit from these principles
AcidosisAcidosisBASE DEFICIT (BD) ge -15 identifies patients that require early
transfusion increased ICU days and risk for ARDS and MOF Ferrara A Mac Arthur J Wright H Hypothermia and Acidosis worsen coagulopathy in the patient requiring massive transfusion Ann J Surg 1990 160515-518
bull BD of ge -15 is strongly associated with the need for massive transfusion and mortality in patients
Rutherford EJ Morris JA Reed GW Hall KS Base deficit stratifies mortality and determines therapy J Trauma 1992 33417-23
bull Patients have an elevated BD before their blood pressure drops to classic ldquohypotensionrdquo levels
bull Acidosis contributes more to coagulopathy more than hypothermia (not reversible)
bull An initial INR ge 15 reliably predicts those who will require massive transfusion
Moore FA Nelson T Massive transfusion in trauma patients tissue hemoglobin oxygen saturation predicts poor outcom J Trauma 2008 Apr 64 (4)1010-23
bull Patients who have a significant injury present with a coagulopathy
bull Severity of injury and mortality is linearly associated with the degree of the initial coagulopathy
Coagulopathy
bull Although resuscitation strategies for severely injured patients who present WITH SHOCK have improved greatly the transfusions are associated with development of MOF and increased intensive care unit (ICU) admissions ICU and hospital length of stay and mortality
bull Malone DL Dunne J Tracy JK Putnam AT Scalea TM Napolitano LM Blood
transfusion independent of shock severity is associated with worse outcome in trauma J Trauma 2003 54898-905
bull Eastridge BJ Malone D Holcomb JB Early predictors of transfusion and mortality
after injury a review of the data-based literature J Trauma 2006 60S20-S25 bull Napolitano L Cumulative risks of early red blood cell transfusion J Trauma 2006
60S26-S34 bull Cotton BA Guy JS Morris JA Jr Abumrad NN The cellular metabolic and systemic
consequences of aggressive fluid resuscitation strategies Shock 2006 26115-121
Current transfusion practices and survival rates of massive transfusion patients vary widely among trauma centers Conventional guidelines may underestimate the optimal plasma and platelet to RBC ratios
Survival in patients is associated with increased plasma and platelet ratios Massive transfusion practice guidelines should aim for a111 ratio of plasma plateletsRBCs bullHolcomb et al Ann Surg 2008248447
Kaplan-Meier survival plot for the first 24 hours after admission for the 4 groups (high plasma (FFPH) or platelet (PltH) to RBC ratio 12 low plasma (FFPL) or platelet (PltL) to RBC ratio 12)
Statistical modeling indicated that a
clinical guideline with mean plasma
RBC ratio equal to 11 would
encompass 98 of patients within
the optimal 12 ratio
Hypotension A systolic blood pressure of 90 mm Hg or less is indicative casualties that have lost over 40 of their blood volume
(~2000 ml in an adult)
They have impending cardiovascular collapse and have significantly increased mortality
The most efficient solution for use in resuscitation is still under debate
Lactated Ringers (LR) and normal isotonic saline solution (NS) remain the
most commonly used isotonic fluids
Although colloid solutions including hyperosmolar colloid and hypertonic
electrolyte compounds have been approved for use as volume expanders
their administration is still under debate in the USA and Europe
Moore FA McKinley BA Moore EE Nathens AB West M Shapiro MB Bankey P Freeman B Harbrecht BG Johnson JL Minei JP Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core standard operating procedures for clinical care III Guidelines for shock resuscitation J Trauma 2006 6182-89 Spahn DR Cerny V Coats TJ Duranteau J Fernandez-Mondejar E Gordini G Stahel PF Hunt BJ Komadina R Neugebauer E Ozier Y Riddez L Schultz A Vincent JL Rossaint R Task Force for Advanced Bleeding Care in Trauma Management of bleeding following major trauma a European guideline Crit Care 2007 11R17
Experimental studies have revealed that resuscitation with NS in the setting of massive hemorrhage requires significantly greater volume and is associated with increased physiologic derangements (for example hyperchloremic acidosis and dilutional coagulopathy) and higher mortality as compared with LR Healey MA Davis RE Liu FC Loomis WH Hoyt DB Lactated ringers is superior to normal saline in a model of massive hemorrhage and resuscitation J Trauma 1998 45894-899 Todd SR Malinoski D Muller PJ Schreiber MA Lactated Ringers is superior to normal saline in the resuscitation of uncontrolled hemorrhagic shock J Trauma 2007 62636-639
Reported data from several studies conducted in critically ill patients have indicated that use of colloid solutions has a significant impact on hemorrhage hemostasis and inflammatory response Roberts I Alderson P Bunn F Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2004 CD000567 Vercueil A Grocott MP Mythen MG Physiology pharmacology and rationale for colloid administration for the maintenance of effective hemodynamic stability in critically ill patients Transfus Med Rev 2005 1993-109 Lee CC Chang IJ Yen ZS Effect of different resuscitation fluids on cytokine response in a rat model of hemorrhagic shock Shock 2005 24177-181
Early administration of blood is one potential treatment to decrease the
need for massive crystalloid solution in hemorrhagic shock however the
limited supply of stored blood and potential adverse effects make this
option logistically difficult and possibly harmful
West MA Sha piro MB Nathens AB Johnson JL Moore EE Minei JP Bankey PE Freeman B Harbrecht BG McKinley BA Moore FA Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core-standard operating procedures for clinical care IV Guidelines for transfusion in the trauma patient J Trauma 2006 61436-439
Moore FA McKinley BA Moore EE Nathens AB West M Shapiro MB Bankey P Freeman B Harbrecht BG Johnson JL Minei JP Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core standard operating procedures for clinical care III Guidelines for shock resuscitation J Trauma 2006 6182-89 Spahn DR Cerny V Coats TJ Duranteau J Fernandez-Mondejar E Gordini G Stahel PF Hunt BJ Komadina R Neugebauer E Ozier Y Riddez L Schultz A Vincent JL Rossaint R Task Force for Advanced Bleeding Care in Trauma Management of bleeding following major trauma a European guideline Crit Care 2007 11R17
Transfusion-related risks include possible development of MOF increased
ICU admissions and length of stay increased hospital length of stay and
mortality
Malone DL Dunne J Tracy JK Putnam AT Scalea TM Napolitano LM Blood transfusion independent of shock severity is associated with worse outcome in trauma J Trauma 2003 54898-905
Eastridge BJ Malone D Holcomb JB Early predictors of transfusion and mortality after injury a review of the data-based literature J Trauma 2006 60S20-S25
Napolitano L Cumulative risks of early red blood cell transfusion J Trauma 2006 60S26-S34
Cotton BA Guy JS Morris JA Jr Abumrad NN The cellular metabolic and systemic consequences of aggressive fluid resuscitation strategies Shock 2006 26115-121
uarr hemorrhage + excessive hemodilution due to
uarr Blood Presion darr blood viscosity darr hematocrit
darr clotting factor concentration
Risks of Aggressive Volume Resuscitation
rFVIIaThe use of rFVIIa was associated with improved early and late survival after severe trauma and massive transfusion
rFVIIa was not associated with increased risk of thrombotic events
The Effect of Recombinant Activated Factor VII on Mortality in Combat-Related Casualties With Severe Trauma and Massive Transfusion
bull Philip C Spinella MD Jeremy G Perkins MD Daniel F McLaughlin MD Sarah E Niles MD MPHKurt W Grathwohl MD Alec C Beekley MD Jose Salinas PhD Sumeru Mehta MD Charles E Wade PhDand John B Holcomb MD J of Trauma- Feb 2008bull Dutton et al J Trauma 200457709 Conclusion consider early use of FVIIa in any pt with uncontrolled hemorrhage who has not responded to surgery or blood component therapy
bull Each unit of blood product biologically active + elevates risk of infections + ARDS (SDRA)Chaiwat et al Anesthesiology 2009110351 n=14070 pts NSCOT database retrospective
bull Older blood association whith elevates infection LOS MOSF + death Weinberg et al J Trauma 200865279
TemperatureA temperature lt 96degF or 35degC is associated with an increase in mortality (cardiac arrest SRP higher abnormal plaquelet function) Burch J Denton J Noble R Physiologic rationale for abbreviated laparotomy Surg Clin North Am 1997 77779-82 Trauma patients that are hypothermic are NOT PERFUSING their tissue
The COAGULATION CASCADE is an enzymatic pathway that degrades with temperature and ceases at 92 FGregory JS Francbeum L Towsened MC Incidence and timing of hypothermia in trauma patients undergoing operations J Trauma 1991 31795-800 If the temperature is lower than 33 C the mortality is 100although Beilman and col think itacutes a significant factor for MODS but not for the mortalityBeilman GJ Blondet JJ Early hypothermia in severely injured trauma patients is a significant risk factor for multiple organ dysfunction syndrome but not mortality Ann Surg 2009 May249(5)845-50
Diagnosis done
Damage Control Resuscitation
1 Hypotensive resuscitation
2 Hemostatic resuscitation
Damage control philosophy can be extended to haemostatic resuscitation
Restoring normal coagulation Minimizing crystalloidTraditional resuscitation strategies dilute the already deficient coagulation factors and increase multiple organ failure
The aggressive hemostatic resuscitation should be combined with equally aggressive control of bleeding
Spahn DR Cerny V Management of bleeding following major trauma a European guidelineCrit Care 2007 11(1) R 17
WAIT AND SEE
SURGEON
ABDOMINAL PACKING is a lifesaving technique for temporary control of severe injury and it is used in damage control surgery schedule
Its possible too applying packs in organ-specific techniques (early abdominal packing)
The median survival of the 70 certainly superior to the obtainable survival with immediate surgical repairbullIMMEDIATE FAILURES are substantially due to bleeding especially in underpacking caseREMOTE FAILURES septic and bound at the time of stay (above the 72 hours) and associated by the coexistence of lesions in these situations is possible a MOF syndrome due to excessive intra-abdominal pressure (overpacking) or to an Abdominal Compartment Syndrome
Stagnitti F Bresadola L Calderale SM Coletti M Ribaldi S Salvi PF Schillaci F Abdominal packing indications and method Ann Ital Chir 2003 Sep-Oct74(5)535-42
Benavides C Garciacutea C Apablaza S Rubilar P Ricaurte F Perales C et al Empaquetamiento hepaacutetico permanente con malla de poliglactina en estallido hepaacutetico secundario a Siacutendrome de Hellp Rev Chil Cir 2004 56 275-278 De la Fuente M Mendoza VH Robledo-Oyarzun F Cierre Temporal de la pared abdominal con polietileno Cir Ciruj 2002 70157-63 Serna VH El Siacutendrome Compartamental Abdominal Tesis de Postgrado Meacutexico 2000
When skin approximation is
not possible a temporary silo
is constructed by suturing a 3-
L cystoscopy irrigation bag
(BOGOTAacute BAG) to the skin
edge with a continuous No 2
nylon suture
The method of closure depends on whether skin approximation produces excessive intra-abdominal hypertension
Towel-clip closure of the skin is preferred because it is quick and easy
The second phase is intra-operative reassessment for hemorrhage control 30 minutes after initial abdominal closure in the operating room focusing on restoration of the patients physiological status specifically reversing hypothermia and coagulopathy
WE CAN HEAR THE HEMORRHAGE
The abdomen is then reopened and assessed for adequacy of hemostasis and for existence of residual mechanical bleeding This practice has allowed surgeons to minimize both early return to the operating room for ongoing hemorrhage and the amount of packing necessary for hemostasis With bleeding effectively controlled the abdomen is reclosed
The patient is transferred to the ICU for continued physiologic restoration in the third phase
Once coagulopathy hypothermia and acidosis have been corrected the patient can be returned to the operating room for definitive management of the injuries in the fourth phase
48-72 h after first surgery
COMPLICATIONS OF DAMAGE CONTROL LAPAROTOMY
1) ACS Acute Compartmental Syndrome
2) ARDS Acute Respiratory Distress of the Adult
3) MOF Multiple organ failure
4) DEATH
ABDOMINAL COMPARTMENT SYNDROME is defined as an intra-abdominal pressure of greater than 20 cm H2O with evidence of impaired organ function ie elevated peak airway pressures (gt45 cm
H2O) oliguria (lt05 mLkg per hour) or cardiovascular dysfunction
(hypotension despite adequate volume resuscitation or if a pulmonary artery catheter is present oxygen delivery index [calculated as milliliters of oxygen per minute per meter squared] of 600) Intra-abdominal pressure was measured indirectly using an indwelling Foley catheter as previously described
Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13 Damage control surgery in the abdomen an approach for the management of severe injured patientsGermanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis NNuffield Department of Surgery John Radcliffe Hospital Oxford UK Curr Opin Crit Care 2006 Aug12(4)346-50 Damage-control laparotomy Lee JC Peitzman AB Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA
ABDOMINAL COMPARTMENT SYNDROME occurred in 17 (33) of
52 Patients undergoing damage-control laparotomy and was
associated with a much higher incidence of ARDS and MOF (71 vs
31 without ACS P = 02)
More importantly our study suggests that primary fascial closure at
the termination of the initial damage-control laparotomy contributes to
the development of ACS as well as subsequent organ failure
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal ypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
Mayberry JC Mullins RJ Crass RA Trunkey DD Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure Arch Surg 1997132957-962
bull MOF Multiple organ failure
Seems to be a major source of postinjury morbidity and the leading cause of in-hospital mortality despite more than 25 years of intense investigation
Eiseman B Beart R Norton L Multiple organ failure Surg Gynecol Obstet 1977144323-326
Bauer AE Durham R Faist E Systemic inflammatory response syndrome (SIRS) multiple organ dysfunction syndrome (MODS) multiple organ failure (MOF) are we winning the battle Shock 19981079-89
The current pathophysiologic model of MOF focuses on uncontrolled systemic
hyperinflammation as a unifying concept following a variety of insults
Moore FA Moore EE Evolving concepts in the pathogenesis of postinjury multiple organ failure Surg Clin North Am 199575257-277
Goris RJ te Boekhorst TP Nuytinck JK Gimbrere JS Multiple-organ failure generalized autodestructive inflammation Arch Surg 19851201109-1115
Nuytinck HK Offermans XJ Kubat K Goris JA Whole-body inflammation in trauma patients an autopsy study Arch Surg 19881231519-1524
Examples that improve the prognosis of MOF include damage control surgery recognition of abdominal compartment syndrome lung protective ventilation
strategies and tight glucose level control
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal hypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
The Acute Respiratory Distress Syndrome Network Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome N Engl J Med 20003421301-1308
Amato MB Barbas CS Medeiros DM et al Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome N Engl J Med 1998338347-354
Van den Berghe G Wouters P Weekers F et al Intensive insulin therapy in the critically ill patients N Engl J Med 20013451359-1367
The incidence of postinjury MOF has been reported to be between 7 and 66 with an associated mortality rate between 31 and 80
Fry DE Pearlstein L Fulton RL Polk HC Jr Multiple system organ failure the role of uncontrolled infection Arch Surg 1980115136-140
Regel G Lobenhoffer P Grotz M Pape HC Lehmann U Tscherne H Treatment results of patients with multiple trauma an analysis of 3406 cases treated between 1972 and 1991 at a German level I trauma center J Trauma 19953870-78
Sauaia A Moore FA Moore EE Norris JM Lezotte DC Hamman RF Multiple organ failure can be predicted as early as 12 hours after injury J Trauma 199845291-303
Nast-Kolb D Aufmkolk M Rucholtz S Obertacke U Waydhas C Multiple organ failure still a major cause of morbidity but not mortality in blunt multiple trauma J Trauma 200151835-842 Durham RM Moran JJ Mazuski JE Shapiro MJ Baue AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
It has been suggested that MOF is disappearing owing to advances in trauma and critical care
Levine JH Durham RM Moran J Bauer A Multiple organ failure is it disappearing World J Surg 199620471-473
Recent reports have not demonstrated a consistent change in either the incidence or the mortality rate associated with postinjury MOF Some groups have reported no change in the incidence but a decreased mortality while others have reported both decreased incidence and mortality compared with historical control subjects
Durham RM Moran JJ Mazuski JE Shapiro MJ Bauer AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
Regel G Grotz M Weltner T Sturm JA Tscherne H Pattern of organ failure following severe trauma World J Surg 199620422-429
Orthopaedic Trauma
Open pelvic fractures in addition to the pelvic ring injury are associated with hemorrhage and neurological insult visceral injuries are more common and a high rate of infection is seen Mortality of open pelvic fractures historically approached 50 Control of bleeding is the most important initial measure followed by debridement and packing of open wounds
Open book- widened symphysis pubis Dislocated Rt SI joint Vallier + Jenkins In Trauma Anesthesia 2008
Type 1 fractures occur due to anterior-posterior
compressioncan cause the symphysis pubis to ldquopoprdquo open leading to pubic rami or ldquoopen
bookrdquo fractures A lateral compression fracture type 2 or vertical sheer facture (Type 3) can
also lead to severe bleeding Into the pelvis Pelvic and acetabular surgery are major surgical interventions
Figura 1- Aplicacioacuten de la engrapadora para la reseccioacuten pulmonar en cuntildea Los segmentos a resecar se limitan por medio de la aplicacioacuten de dispositivos de grapado orientados en direcciones perpendiculares tratando de mantener la mayor cantidad de tejido sano
Insercioacuten de engrapadora lineal cortante a traveacutes de los orificios del tracto de la herida pulmonar penetrante
Figura 3- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales con fuga aeacuterea visible
Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales
Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
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-
The MORE IMPORTANT PHASE is to IDENTIFY the appropriate candidate
bull Acidosis- Base Deficit gt - 6 phlt 72bull Coagulopathy INR gt 15 or TTPA gt 60 scbull Hypotension Systolic BP lt 90 mmHgbull Need of transfusion gt 4 l red cell contentsbull Temperature lt 96 5 F=34 Cbull Pattern recognition
bull Weak or absent radial pulse bull Abnormal mental statusbull Severe Traumatic Injury
DEATH
HYPOTHERMIA
ACIDOSIS
COAGULOPATHY
The Lethal TriadThe Lethal TriadThe Lethal TriadThe Lethal Triad
Soto S Oettinger R Brousse J Saacutenchez G Cirugiacutea de Control de Dantildeos Enfrentamiento actual del Trauma Cuad Cir 20031795-102
The OBJECTIVES are
1) STOP HEMORRHAGE to correct underlying coagulopathy
2) MINIMIZE PERITONEAL CONTAMINATION and its secondary inflammatory response
3) ENCLOSE THE ABDOMINAL CONTENTS to protect viscera and minimize protein loss
4) The final objective of this damage-control phase is CLOSURE OF THE ABDOMINAL CAVITY
bullRequires robust MEDICAL SETTING
bullNeed system approach to deliver casualties to MOST CAPABLE FACILITIES
bullIsolated and far forward facilities can still benefit from these principles
AcidosisAcidosisBASE DEFICIT (BD) ge -15 identifies patients that require early
transfusion increased ICU days and risk for ARDS and MOF Ferrara A Mac Arthur J Wright H Hypothermia and Acidosis worsen coagulopathy in the patient requiring massive transfusion Ann J Surg 1990 160515-518
bull BD of ge -15 is strongly associated with the need for massive transfusion and mortality in patients
Rutherford EJ Morris JA Reed GW Hall KS Base deficit stratifies mortality and determines therapy J Trauma 1992 33417-23
bull Patients have an elevated BD before their blood pressure drops to classic ldquohypotensionrdquo levels
bull Acidosis contributes more to coagulopathy more than hypothermia (not reversible)
bull An initial INR ge 15 reliably predicts those who will require massive transfusion
Moore FA Nelson T Massive transfusion in trauma patients tissue hemoglobin oxygen saturation predicts poor outcom J Trauma 2008 Apr 64 (4)1010-23
bull Patients who have a significant injury present with a coagulopathy
bull Severity of injury and mortality is linearly associated with the degree of the initial coagulopathy
Coagulopathy
bull Although resuscitation strategies for severely injured patients who present WITH SHOCK have improved greatly the transfusions are associated with development of MOF and increased intensive care unit (ICU) admissions ICU and hospital length of stay and mortality
bull Malone DL Dunne J Tracy JK Putnam AT Scalea TM Napolitano LM Blood
transfusion independent of shock severity is associated with worse outcome in trauma J Trauma 2003 54898-905
bull Eastridge BJ Malone D Holcomb JB Early predictors of transfusion and mortality
after injury a review of the data-based literature J Trauma 2006 60S20-S25 bull Napolitano L Cumulative risks of early red blood cell transfusion J Trauma 2006
60S26-S34 bull Cotton BA Guy JS Morris JA Jr Abumrad NN The cellular metabolic and systemic
consequences of aggressive fluid resuscitation strategies Shock 2006 26115-121
Current transfusion practices and survival rates of massive transfusion patients vary widely among trauma centers Conventional guidelines may underestimate the optimal plasma and platelet to RBC ratios
Survival in patients is associated with increased plasma and platelet ratios Massive transfusion practice guidelines should aim for a111 ratio of plasma plateletsRBCs bullHolcomb et al Ann Surg 2008248447
Kaplan-Meier survival plot for the first 24 hours after admission for the 4 groups (high plasma (FFPH) or platelet (PltH) to RBC ratio 12 low plasma (FFPL) or platelet (PltL) to RBC ratio 12)
Statistical modeling indicated that a
clinical guideline with mean plasma
RBC ratio equal to 11 would
encompass 98 of patients within
the optimal 12 ratio
Hypotension A systolic blood pressure of 90 mm Hg or less is indicative casualties that have lost over 40 of their blood volume
(~2000 ml in an adult)
They have impending cardiovascular collapse and have significantly increased mortality
The most efficient solution for use in resuscitation is still under debate
Lactated Ringers (LR) and normal isotonic saline solution (NS) remain the
most commonly used isotonic fluids
Although colloid solutions including hyperosmolar colloid and hypertonic
electrolyte compounds have been approved for use as volume expanders
their administration is still under debate in the USA and Europe
Moore FA McKinley BA Moore EE Nathens AB West M Shapiro MB Bankey P Freeman B Harbrecht BG Johnson JL Minei JP Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core standard operating procedures for clinical care III Guidelines for shock resuscitation J Trauma 2006 6182-89 Spahn DR Cerny V Coats TJ Duranteau J Fernandez-Mondejar E Gordini G Stahel PF Hunt BJ Komadina R Neugebauer E Ozier Y Riddez L Schultz A Vincent JL Rossaint R Task Force for Advanced Bleeding Care in Trauma Management of bleeding following major trauma a European guideline Crit Care 2007 11R17
Experimental studies have revealed that resuscitation with NS in the setting of massive hemorrhage requires significantly greater volume and is associated with increased physiologic derangements (for example hyperchloremic acidosis and dilutional coagulopathy) and higher mortality as compared with LR Healey MA Davis RE Liu FC Loomis WH Hoyt DB Lactated ringers is superior to normal saline in a model of massive hemorrhage and resuscitation J Trauma 1998 45894-899 Todd SR Malinoski D Muller PJ Schreiber MA Lactated Ringers is superior to normal saline in the resuscitation of uncontrolled hemorrhagic shock J Trauma 2007 62636-639
Reported data from several studies conducted in critically ill patients have indicated that use of colloid solutions has a significant impact on hemorrhage hemostasis and inflammatory response Roberts I Alderson P Bunn F Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2004 CD000567 Vercueil A Grocott MP Mythen MG Physiology pharmacology and rationale for colloid administration for the maintenance of effective hemodynamic stability in critically ill patients Transfus Med Rev 2005 1993-109 Lee CC Chang IJ Yen ZS Effect of different resuscitation fluids on cytokine response in a rat model of hemorrhagic shock Shock 2005 24177-181
Early administration of blood is one potential treatment to decrease the
need for massive crystalloid solution in hemorrhagic shock however the
limited supply of stored blood and potential adverse effects make this
option logistically difficult and possibly harmful
West MA Sha piro MB Nathens AB Johnson JL Moore EE Minei JP Bankey PE Freeman B Harbrecht BG McKinley BA Moore FA Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core-standard operating procedures for clinical care IV Guidelines for transfusion in the trauma patient J Trauma 2006 61436-439
Moore FA McKinley BA Moore EE Nathens AB West M Shapiro MB Bankey P Freeman B Harbrecht BG Johnson JL Minei JP Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core standard operating procedures for clinical care III Guidelines for shock resuscitation J Trauma 2006 6182-89 Spahn DR Cerny V Coats TJ Duranteau J Fernandez-Mondejar E Gordini G Stahel PF Hunt BJ Komadina R Neugebauer E Ozier Y Riddez L Schultz A Vincent JL Rossaint R Task Force for Advanced Bleeding Care in Trauma Management of bleeding following major trauma a European guideline Crit Care 2007 11R17
Transfusion-related risks include possible development of MOF increased
ICU admissions and length of stay increased hospital length of stay and
mortality
Malone DL Dunne J Tracy JK Putnam AT Scalea TM Napolitano LM Blood transfusion independent of shock severity is associated with worse outcome in trauma J Trauma 2003 54898-905
Eastridge BJ Malone D Holcomb JB Early predictors of transfusion and mortality after injury a review of the data-based literature J Trauma 2006 60S20-S25
Napolitano L Cumulative risks of early red blood cell transfusion J Trauma 2006 60S26-S34
Cotton BA Guy JS Morris JA Jr Abumrad NN The cellular metabolic and systemic consequences of aggressive fluid resuscitation strategies Shock 2006 26115-121
uarr hemorrhage + excessive hemodilution due to
uarr Blood Presion darr blood viscosity darr hematocrit
darr clotting factor concentration
Risks of Aggressive Volume Resuscitation
rFVIIaThe use of rFVIIa was associated with improved early and late survival after severe trauma and massive transfusion
rFVIIa was not associated with increased risk of thrombotic events
The Effect of Recombinant Activated Factor VII on Mortality in Combat-Related Casualties With Severe Trauma and Massive Transfusion
bull Philip C Spinella MD Jeremy G Perkins MD Daniel F McLaughlin MD Sarah E Niles MD MPHKurt W Grathwohl MD Alec C Beekley MD Jose Salinas PhD Sumeru Mehta MD Charles E Wade PhDand John B Holcomb MD J of Trauma- Feb 2008bull Dutton et al J Trauma 200457709 Conclusion consider early use of FVIIa in any pt with uncontrolled hemorrhage who has not responded to surgery or blood component therapy
bull Each unit of blood product biologically active + elevates risk of infections + ARDS (SDRA)Chaiwat et al Anesthesiology 2009110351 n=14070 pts NSCOT database retrospective
bull Older blood association whith elevates infection LOS MOSF + death Weinberg et al J Trauma 200865279
TemperatureA temperature lt 96degF or 35degC is associated with an increase in mortality (cardiac arrest SRP higher abnormal plaquelet function) Burch J Denton J Noble R Physiologic rationale for abbreviated laparotomy Surg Clin North Am 1997 77779-82 Trauma patients that are hypothermic are NOT PERFUSING their tissue
The COAGULATION CASCADE is an enzymatic pathway that degrades with temperature and ceases at 92 FGregory JS Francbeum L Towsened MC Incidence and timing of hypothermia in trauma patients undergoing operations J Trauma 1991 31795-800 If the temperature is lower than 33 C the mortality is 100although Beilman and col think itacutes a significant factor for MODS but not for the mortalityBeilman GJ Blondet JJ Early hypothermia in severely injured trauma patients is a significant risk factor for multiple organ dysfunction syndrome but not mortality Ann Surg 2009 May249(5)845-50
Diagnosis done
Damage Control Resuscitation
1 Hypotensive resuscitation
2 Hemostatic resuscitation
Damage control philosophy can be extended to haemostatic resuscitation
Restoring normal coagulation Minimizing crystalloidTraditional resuscitation strategies dilute the already deficient coagulation factors and increase multiple organ failure
The aggressive hemostatic resuscitation should be combined with equally aggressive control of bleeding
Spahn DR Cerny V Management of bleeding following major trauma a European guidelineCrit Care 2007 11(1) R 17
WAIT AND SEE
SURGEON
ABDOMINAL PACKING is a lifesaving technique for temporary control of severe injury and it is used in damage control surgery schedule
Its possible too applying packs in organ-specific techniques (early abdominal packing)
The median survival of the 70 certainly superior to the obtainable survival with immediate surgical repairbullIMMEDIATE FAILURES are substantially due to bleeding especially in underpacking caseREMOTE FAILURES septic and bound at the time of stay (above the 72 hours) and associated by the coexistence of lesions in these situations is possible a MOF syndrome due to excessive intra-abdominal pressure (overpacking) or to an Abdominal Compartment Syndrome
Stagnitti F Bresadola L Calderale SM Coletti M Ribaldi S Salvi PF Schillaci F Abdominal packing indications and method Ann Ital Chir 2003 Sep-Oct74(5)535-42
Benavides C Garciacutea C Apablaza S Rubilar P Ricaurte F Perales C et al Empaquetamiento hepaacutetico permanente con malla de poliglactina en estallido hepaacutetico secundario a Siacutendrome de Hellp Rev Chil Cir 2004 56 275-278 De la Fuente M Mendoza VH Robledo-Oyarzun F Cierre Temporal de la pared abdominal con polietileno Cir Ciruj 2002 70157-63 Serna VH El Siacutendrome Compartamental Abdominal Tesis de Postgrado Meacutexico 2000
When skin approximation is
not possible a temporary silo
is constructed by suturing a 3-
L cystoscopy irrigation bag
(BOGOTAacute BAG) to the skin
edge with a continuous No 2
nylon suture
The method of closure depends on whether skin approximation produces excessive intra-abdominal hypertension
Towel-clip closure of the skin is preferred because it is quick and easy
The second phase is intra-operative reassessment for hemorrhage control 30 minutes after initial abdominal closure in the operating room focusing on restoration of the patients physiological status specifically reversing hypothermia and coagulopathy
WE CAN HEAR THE HEMORRHAGE
The abdomen is then reopened and assessed for adequacy of hemostasis and for existence of residual mechanical bleeding This practice has allowed surgeons to minimize both early return to the operating room for ongoing hemorrhage and the amount of packing necessary for hemostasis With bleeding effectively controlled the abdomen is reclosed
The patient is transferred to the ICU for continued physiologic restoration in the third phase
Once coagulopathy hypothermia and acidosis have been corrected the patient can be returned to the operating room for definitive management of the injuries in the fourth phase
48-72 h after first surgery
COMPLICATIONS OF DAMAGE CONTROL LAPAROTOMY
1) ACS Acute Compartmental Syndrome
2) ARDS Acute Respiratory Distress of the Adult
3) MOF Multiple organ failure
4) DEATH
ABDOMINAL COMPARTMENT SYNDROME is defined as an intra-abdominal pressure of greater than 20 cm H2O with evidence of impaired organ function ie elevated peak airway pressures (gt45 cm
H2O) oliguria (lt05 mLkg per hour) or cardiovascular dysfunction
(hypotension despite adequate volume resuscitation or if a pulmonary artery catheter is present oxygen delivery index [calculated as milliliters of oxygen per minute per meter squared] of 600) Intra-abdominal pressure was measured indirectly using an indwelling Foley catheter as previously described
Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13 Damage control surgery in the abdomen an approach for the management of severe injured patientsGermanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis NNuffield Department of Surgery John Radcliffe Hospital Oxford UK Curr Opin Crit Care 2006 Aug12(4)346-50 Damage-control laparotomy Lee JC Peitzman AB Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA
ABDOMINAL COMPARTMENT SYNDROME occurred in 17 (33) of
52 Patients undergoing damage-control laparotomy and was
associated with a much higher incidence of ARDS and MOF (71 vs
31 without ACS P = 02)
More importantly our study suggests that primary fascial closure at
the termination of the initial damage-control laparotomy contributes to
the development of ACS as well as subsequent organ failure
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal ypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
Mayberry JC Mullins RJ Crass RA Trunkey DD Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure Arch Surg 1997132957-962
bull MOF Multiple organ failure
Seems to be a major source of postinjury morbidity and the leading cause of in-hospital mortality despite more than 25 years of intense investigation
Eiseman B Beart R Norton L Multiple organ failure Surg Gynecol Obstet 1977144323-326
Bauer AE Durham R Faist E Systemic inflammatory response syndrome (SIRS) multiple organ dysfunction syndrome (MODS) multiple organ failure (MOF) are we winning the battle Shock 19981079-89
The current pathophysiologic model of MOF focuses on uncontrolled systemic
hyperinflammation as a unifying concept following a variety of insults
Moore FA Moore EE Evolving concepts in the pathogenesis of postinjury multiple organ failure Surg Clin North Am 199575257-277
Goris RJ te Boekhorst TP Nuytinck JK Gimbrere JS Multiple-organ failure generalized autodestructive inflammation Arch Surg 19851201109-1115
Nuytinck HK Offermans XJ Kubat K Goris JA Whole-body inflammation in trauma patients an autopsy study Arch Surg 19881231519-1524
Examples that improve the prognosis of MOF include damage control surgery recognition of abdominal compartment syndrome lung protective ventilation
strategies and tight glucose level control
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal hypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
The Acute Respiratory Distress Syndrome Network Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome N Engl J Med 20003421301-1308
Amato MB Barbas CS Medeiros DM et al Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome N Engl J Med 1998338347-354
Van den Berghe G Wouters P Weekers F et al Intensive insulin therapy in the critically ill patients N Engl J Med 20013451359-1367
The incidence of postinjury MOF has been reported to be between 7 and 66 with an associated mortality rate between 31 and 80
Fry DE Pearlstein L Fulton RL Polk HC Jr Multiple system organ failure the role of uncontrolled infection Arch Surg 1980115136-140
Regel G Lobenhoffer P Grotz M Pape HC Lehmann U Tscherne H Treatment results of patients with multiple trauma an analysis of 3406 cases treated between 1972 and 1991 at a German level I trauma center J Trauma 19953870-78
Sauaia A Moore FA Moore EE Norris JM Lezotte DC Hamman RF Multiple organ failure can be predicted as early as 12 hours after injury J Trauma 199845291-303
Nast-Kolb D Aufmkolk M Rucholtz S Obertacke U Waydhas C Multiple organ failure still a major cause of morbidity but not mortality in blunt multiple trauma J Trauma 200151835-842 Durham RM Moran JJ Mazuski JE Shapiro MJ Baue AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
It has been suggested that MOF is disappearing owing to advances in trauma and critical care
Levine JH Durham RM Moran J Bauer A Multiple organ failure is it disappearing World J Surg 199620471-473
Recent reports have not demonstrated a consistent change in either the incidence or the mortality rate associated with postinjury MOF Some groups have reported no change in the incidence but a decreased mortality while others have reported both decreased incidence and mortality compared with historical control subjects
Durham RM Moran JJ Mazuski JE Shapiro MJ Bauer AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
Regel G Grotz M Weltner T Sturm JA Tscherne H Pattern of organ failure following severe trauma World J Surg 199620422-429
Orthopaedic Trauma
Open pelvic fractures in addition to the pelvic ring injury are associated with hemorrhage and neurological insult visceral injuries are more common and a high rate of infection is seen Mortality of open pelvic fractures historically approached 50 Control of bleeding is the most important initial measure followed by debridement and packing of open wounds
Open book- widened symphysis pubis Dislocated Rt SI joint Vallier + Jenkins In Trauma Anesthesia 2008
Type 1 fractures occur due to anterior-posterior
compressioncan cause the symphysis pubis to ldquopoprdquo open leading to pubic rami or ldquoopen
bookrdquo fractures A lateral compression fracture type 2 or vertical sheer facture (Type 3) can
also lead to severe bleeding Into the pelvis Pelvic and acetabular surgery are major surgical interventions
Figura 1- Aplicacioacuten de la engrapadora para la reseccioacuten pulmonar en cuntildea Los segmentos a resecar se limitan por medio de la aplicacioacuten de dispositivos de grapado orientados en direcciones perpendiculares tratando de mantener la mayor cantidad de tejido sano
Insercioacuten de engrapadora lineal cortante a traveacutes de los orificios del tracto de la herida pulmonar penetrante
Figura 3- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales con fuga aeacuterea visible
Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales
Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
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-
DEATH
HYPOTHERMIA
ACIDOSIS
COAGULOPATHY
The Lethal TriadThe Lethal TriadThe Lethal TriadThe Lethal Triad
Soto S Oettinger R Brousse J Saacutenchez G Cirugiacutea de Control de Dantildeos Enfrentamiento actual del Trauma Cuad Cir 20031795-102
The OBJECTIVES are
1) STOP HEMORRHAGE to correct underlying coagulopathy
2) MINIMIZE PERITONEAL CONTAMINATION and its secondary inflammatory response
3) ENCLOSE THE ABDOMINAL CONTENTS to protect viscera and minimize protein loss
4) The final objective of this damage-control phase is CLOSURE OF THE ABDOMINAL CAVITY
bullRequires robust MEDICAL SETTING
bullNeed system approach to deliver casualties to MOST CAPABLE FACILITIES
bullIsolated and far forward facilities can still benefit from these principles
AcidosisAcidosisBASE DEFICIT (BD) ge -15 identifies patients that require early
transfusion increased ICU days and risk for ARDS and MOF Ferrara A Mac Arthur J Wright H Hypothermia and Acidosis worsen coagulopathy in the patient requiring massive transfusion Ann J Surg 1990 160515-518
bull BD of ge -15 is strongly associated with the need for massive transfusion and mortality in patients
Rutherford EJ Morris JA Reed GW Hall KS Base deficit stratifies mortality and determines therapy J Trauma 1992 33417-23
bull Patients have an elevated BD before their blood pressure drops to classic ldquohypotensionrdquo levels
bull Acidosis contributes more to coagulopathy more than hypothermia (not reversible)
bull An initial INR ge 15 reliably predicts those who will require massive transfusion
Moore FA Nelson T Massive transfusion in trauma patients tissue hemoglobin oxygen saturation predicts poor outcom J Trauma 2008 Apr 64 (4)1010-23
bull Patients who have a significant injury present with a coagulopathy
bull Severity of injury and mortality is linearly associated with the degree of the initial coagulopathy
Coagulopathy
bull Although resuscitation strategies for severely injured patients who present WITH SHOCK have improved greatly the transfusions are associated with development of MOF and increased intensive care unit (ICU) admissions ICU and hospital length of stay and mortality
bull Malone DL Dunne J Tracy JK Putnam AT Scalea TM Napolitano LM Blood
transfusion independent of shock severity is associated with worse outcome in trauma J Trauma 2003 54898-905
bull Eastridge BJ Malone D Holcomb JB Early predictors of transfusion and mortality
after injury a review of the data-based literature J Trauma 2006 60S20-S25 bull Napolitano L Cumulative risks of early red blood cell transfusion J Trauma 2006
60S26-S34 bull Cotton BA Guy JS Morris JA Jr Abumrad NN The cellular metabolic and systemic
consequences of aggressive fluid resuscitation strategies Shock 2006 26115-121
Current transfusion practices and survival rates of massive transfusion patients vary widely among trauma centers Conventional guidelines may underestimate the optimal plasma and platelet to RBC ratios
Survival in patients is associated with increased plasma and platelet ratios Massive transfusion practice guidelines should aim for a111 ratio of plasma plateletsRBCs bullHolcomb et al Ann Surg 2008248447
Kaplan-Meier survival plot for the first 24 hours after admission for the 4 groups (high plasma (FFPH) or platelet (PltH) to RBC ratio 12 low plasma (FFPL) or platelet (PltL) to RBC ratio 12)
Statistical modeling indicated that a
clinical guideline with mean plasma
RBC ratio equal to 11 would
encompass 98 of patients within
the optimal 12 ratio
Hypotension A systolic blood pressure of 90 mm Hg or less is indicative casualties that have lost over 40 of their blood volume
(~2000 ml in an adult)
They have impending cardiovascular collapse and have significantly increased mortality
The most efficient solution for use in resuscitation is still under debate
Lactated Ringers (LR) and normal isotonic saline solution (NS) remain the
most commonly used isotonic fluids
Although colloid solutions including hyperosmolar colloid and hypertonic
electrolyte compounds have been approved for use as volume expanders
their administration is still under debate in the USA and Europe
Moore FA McKinley BA Moore EE Nathens AB West M Shapiro MB Bankey P Freeman B Harbrecht BG Johnson JL Minei JP Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core standard operating procedures for clinical care III Guidelines for shock resuscitation J Trauma 2006 6182-89 Spahn DR Cerny V Coats TJ Duranteau J Fernandez-Mondejar E Gordini G Stahel PF Hunt BJ Komadina R Neugebauer E Ozier Y Riddez L Schultz A Vincent JL Rossaint R Task Force for Advanced Bleeding Care in Trauma Management of bleeding following major trauma a European guideline Crit Care 2007 11R17
Experimental studies have revealed that resuscitation with NS in the setting of massive hemorrhage requires significantly greater volume and is associated with increased physiologic derangements (for example hyperchloremic acidosis and dilutional coagulopathy) and higher mortality as compared with LR Healey MA Davis RE Liu FC Loomis WH Hoyt DB Lactated ringers is superior to normal saline in a model of massive hemorrhage and resuscitation J Trauma 1998 45894-899 Todd SR Malinoski D Muller PJ Schreiber MA Lactated Ringers is superior to normal saline in the resuscitation of uncontrolled hemorrhagic shock J Trauma 2007 62636-639
Reported data from several studies conducted in critically ill patients have indicated that use of colloid solutions has a significant impact on hemorrhage hemostasis and inflammatory response Roberts I Alderson P Bunn F Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2004 CD000567 Vercueil A Grocott MP Mythen MG Physiology pharmacology and rationale for colloid administration for the maintenance of effective hemodynamic stability in critically ill patients Transfus Med Rev 2005 1993-109 Lee CC Chang IJ Yen ZS Effect of different resuscitation fluids on cytokine response in a rat model of hemorrhagic shock Shock 2005 24177-181
Early administration of blood is one potential treatment to decrease the
need for massive crystalloid solution in hemorrhagic shock however the
limited supply of stored blood and potential adverse effects make this
option logistically difficult and possibly harmful
West MA Sha piro MB Nathens AB Johnson JL Moore EE Minei JP Bankey PE Freeman B Harbrecht BG McKinley BA Moore FA Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core-standard operating procedures for clinical care IV Guidelines for transfusion in the trauma patient J Trauma 2006 61436-439
Moore FA McKinley BA Moore EE Nathens AB West M Shapiro MB Bankey P Freeman B Harbrecht BG Johnson JL Minei JP Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core standard operating procedures for clinical care III Guidelines for shock resuscitation J Trauma 2006 6182-89 Spahn DR Cerny V Coats TJ Duranteau J Fernandez-Mondejar E Gordini G Stahel PF Hunt BJ Komadina R Neugebauer E Ozier Y Riddez L Schultz A Vincent JL Rossaint R Task Force for Advanced Bleeding Care in Trauma Management of bleeding following major trauma a European guideline Crit Care 2007 11R17
Transfusion-related risks include possible development of MOF increased
ICU admissions and length of stay increased hospital length of stay and
mortality
Malone DL Dunne J Tracy JK Putnam AT Scalea TM Napolitano LM Blood transfusion independent of shock severity is associated with worse outcome in trauma J Trauma 2003 54898-905
Eastridge BJ Malone D Holcomb JB Early predictors of transfusion and mortality after injury a review of the data-based literature J Trauma 2006 60S20-S25
Napolitano L Cumulative risks of early red blood cell transfusion J Trauma 2006 60S26-S34
Cotton BA Guy JS Morris JA Jr Abumrad NN The cellular metabolic and systemic consequences of aggressive fluid resuscitation strategies Shock 2006 26115-121
uarr hemorrhage + excessive hemodilution due to
uarr Blood Presion darr blood viscosity darr hematocrit
darr clotting factor concentration
Risks of Aggressive Volume Resuscitation
rFVIIaThe use of rFVIIa was associated with improved early and late survival after severe trauma and massive transfusion
rFVIIa was not associated with increased risk of thrombotic events
The Effect of Recombinant Activated Factor VII on Mortality in Combat-Related Casualties With Severe Trauma and Massive Transfusion
bull Philip C Spinella MD Jeremy G Perkins MD Daniel F McLaughlin MD Sarah E Niles MD MPHKurt W Grathwohl MD Alec C Beekley MD Jose Salinas PhD Sumeru Mehta MD Charles E Wade PhDand John B Holcomb MD J of Trauma- Feb 2008bull Dutton et al J Trauma 200457709 Conclusion consider early use of FVIIa in any pt with uncontrolled hemorrhage who has not responded to surgery or blood component therapy
bull Each unit of blood product biologically active + elevates risk of infections + ARDS (SDRA)Chaiwat et al Anesthesiology 2009110351 n=14070 pts NSCOT database retrospective
bull Older blood association whith elevates infection LOS MOSF + death Weinberg et al J Trauma 200865279
TemperatureA temperature lt 96degF or 35degC is associated with an increase in mortality (cardiac arrest SRP higher abnormal plaquelet function) Burch J Denton J Noble R Physiologic rationale for abbreviated laparotomy Surg Clin North Am 1997 77779-82 Trauma patients that are hypothermic are NOT PERFUSING their tissue
The COAGULATION CASCADE is an enzymatic pathway that degrades with temperature and ceases at 92 FGregory JS Francbeum L Towsened MC Incidence and timing of hypothermia in trauma patients undergoing operations J Trauma 1991 31795-800 If the temperature is lower than 33 C the mortality is 100although Beilman and col think itacutes a significant factor for MODS but not for the mortalityBeilman GJ Blondet JJ Early hypothermia in severely injured trauma patients is a significant risk factor for multiple organ dysfunction syndrome but not mortality Ann Surg 2009 May249(5)845-50
Diagnosis done
Damage Control Resuscitation
1 Hypotensive resuscitation
2 Hemostatic resuscitation
Damage control philosophy can be extended to haemostatic resuscitation
Restoring normal coagulation Minimizing crystalloidTraditional resuscitation strategies dilute the already deficient coagulation factors and increase multiple organ failure
The aggressive hemostatic resuscitation should be combined with equally aggressive control of bleeding
Spahn DR Cerny V Management of bleeding following major trauma a European guidelineCrit Care 2007 11(1) R 17
WAIT AND SEE
SURGEON
ABDOMINAL PACKING is a lifesaving technique for temporary control of severe injury and it is used in damage control surgery schedule
Its possible too applying packs in organ-specific techniques (early abdominal packing)
The median survival of the 70 certainly superior to the obtainable survival with immediate surgical repairbullIMMEDIATE FAILURES are substantially due to bleeding especially in underpacking caseREMOTE FAILURES septic and bound at the time of stay (above the 72 hours) and associated by the coexistence of lesions in these situations is possible a MOF syndrome due to excessive intra-abdominal pressure (overpacking) or to an Abdominal Compartment Syndrome
Stagnitti F Bresadola L Calderale SM Coletti M Ribaldi S Salvi PF Schillaci F Abdominal packing indications and method Ann Ital Chir 2003 Sep-Oct74(5)535-42
Benavides C Garciacutea C Apablaza S Rubilar P Ricaurte F Perales C et al Empaquetamiento hepaacutetico permanente con malla de poliglactina en estallido hepaacutetico secundario a Siacutendrome de Hellp Rev Chil Cir 2004 56 275-278 De la Fuente M Mendoza VH Robledo-Oyarzun F Cierre Temporal de la pared abdominal con polietileno Cir Ciruj 2002 70157-63 Serna VH El Siacutendrome Compartamental Abdominal Tesis de Postgrado Meacutexico 2000
When skin approximation is
not possible a temporary silo
is constructed by suturing a 3-
L cystoscopy irrigation bag
(BOGOTAacute BAG) to the skin
edge with a continuous No 2
nylon suture
The method of closure depends on whether skin approximation produces excessive intra-abdominal hypertension
Towel-clip closure of the skin is preferred because it is quick and easy
The second phase is intra-operative reassessment for hemorrhage control 30 minutes after initial abdominal closure in the operating room focusing on restoration of the patients physiological status specifically reversing hypothermia and coagulopathy
WE CAN HEAR THE HEMORRHAGE
The abdomen is then reopened and assessed for adequacy of hemostasis and for existence of residual mechanical bleeding This practice has allowed surgeons to minimize both early return to the operating room for ongoing hemorrhage and the amount of packing necessary for hemostasis With bleeding effectively controlled the abdomen is reclosed
The patient is transferred to the ICU for continued physiologic restoration in the third phase
Once coagulopathy hypothermia and acidosis have been corrected the patient can be returned to the operating room for definitive management of the injuries in the fourth phase
48-72 h after first surgery
COMPLICATIONS OF DAMAGE CONTROL LAPAROTOMY
1) ACS Acute Compartmental Syndrome
2) ARDS Acute Respiratory Distress of the Adult
3) MOF Multiple organ failure
4) DEATH
ABDOMINAL COMPARTMENT SYNDROME is defined as an intra-abdominal pressure of greater than 20 cm H2O with evidence of impaired organ function ie elevated peak airway pressures (gt45 cm
H2O) oliguria (lt05 mLkg per hour) or cardiovascular dysfunction
(hypotension despite adequate volume resuscitation or if a pulmonary artery catheter is present oxygen delivery index [calculated as milliliters of oxygen per minute per meter squared] of 600) Intra-abdominal pressure was measured indirectly using an indwelling Foley catheter as previously described
Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13 Damage control surgery in the abdomen an approach for the management of severe injured patientsGermanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis NNuffield Department of Surgery John Radcliffe Hospital Oxford UK Curr Opin Crit Care 2006 Aug12(4)346-50 Damage-control laparotomy Lee JC Peitzman AB Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA
ABDOMINAL COMPARTMENT SYNDROME occurred in 17 (33) of
52 Patients undergoing damage-control laparotomy and was
associated with a much higher incidence of ARDS and MOF (71 vs
31 without ACS P = 02)
More importantly our study suggests that primary fascial closure at
the termination of the initial damage-control laparotomy contributes to
the development of ACS as well as subsequent organ failure
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal ypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
Mayberry JC Mullins RJ Crass RA Trunkey DD Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure Arch Surg 1997132957-962
bull MOF Multiple organ failure
Seems to be a major source of postinjury morbidity and the leading cause of in-hospital mortality despite more than 25 years of intense investigation
Eiseman B Beart R Norton L Multiple organ failure Surg Gynecol Obstet 1977144323-326
Bauer AE Durham R Faist E Systemic inflammatory response syndrome (SIRS) multiple organ dysfunction syndrome (MODS) multiple organ failure (MOF) are we winning the battle Shock 19981079-89
The current pathophysiologic model of MOF focuses on uncontrolled systemic
hyperinflammation as a unifying concept following a variety of insults
Moore FA Moore EE Evolving concepts in the pathogenesis of postinjury multiple organ failure Surg Clin North Am 199575257-277
Goris RJ te Boekhorst TP Nuytinck JK Gimbrere JS Multiple-organ failure generalized autodestructive inflammation Arch Surg 19851201109-1115
Nuytinck HK Offermans XJ Kubat K Goris JA Whole-body inflammation in trauma patients an autopsy study Arch Surg 19881231519-1524
Examples that improve the prognosis of MOF include damage control surgery recognition of abdominal compartment syndrome lung protective ventilation
strategies and tight glucose level control
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal hypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
The Acute Respiratory Distress Syndrome Network Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome N Engl J Med 20003421301-1308
Amato MB Barbas CS Medeiros DM et al Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome N Engl J Med 1998338347-354
Van den Berghe G Wouters P Weekers F et al Intensive insulin therapy in the critically ill patients N Engl J Med 20013451359-1367
The incidence of postinjury MOF has been reported to be between 7 and 66 with an associated mortality rate between 31 and 80
Fry DE Pearlstein L Fulton RL Polk HC Jr Multiple system organ failure the role of uncontrolled infection Arch Surg 1980115136-140
Regel G Lobenhoffer P Grotz M Pape HC Lehmann U Tscherne H Treatment results of patients with multiple trauma an analysis of 3406 cases treated between 1972 and 1991 at a German level I trauma center J Trauma 19953870-78
Sauaia A Moore FA Moore EE Norris JM Lezotte DC Hamman RF Multiple organ failure can be predicted as early as 12 hours after injury J Trauma 199845291-303
Nast-Kolb D Aufmkolk M Rucholtz S Obertacke U Waydhas C Multiple organ failure still a major cause of morbidity but not mortality in blunt multiple trauma J Trauma 200151835-842 Durham RM Moran JJ Mazuski JE Shapiro MJ Baue AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
It has been suggested that MOF is disappearing owing to advances in trauma and critical care
Levine JH Durham RM Moran J Bauer A Multiple organ failure is it disappearing World J Surg 199620471-473
Recent reports have not demonstrated a consistent change in either the incidence or the mortality rate associated with postinjury MOF Some groups have reported no change in the incidence but a decreased mortality while others have reported both decreased incidence and mortality compared with historical control subjects
Durham RM Moran JJ Mazuski JE Shapiro MJ Bauer AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
Regel G Grotz M Weltner T Sturm JA Tscherne H Pattern of organ failure following severe trauma World J Surg 199620422-429
Orthopaedic Trauma
Open pelvic fractures in addition to the pelvic ring injury are associated with hemorrhage and neurological insult visceral injuries are more common and a high rate of infection is seen Mortality of open pelvic fractures historically approached 50 Control of bleeding is the most important initial measure followed by debridement and packing of open wounds
Open book- widened symphysis pubis Dislocated Rt SI joint Vallier + Jenkins In Trauma Anesthesia 2008
Type 1 fractures occur due to anterior-posterior
compressioncan cause the symphysis pubis to ldquopoprdquo open leading to pubic rami or ldquoopen
bookrdquo fractures A lateral compression fracture type 2 or vertical sheer facture (Type 3) can
also lead to severe bleeding Into the pelvis Pelvic and acetabular surgery are major surgical interventions
Figura 1- Aplicacioacuten de la engrapadora para la reseccioacuten pulmonar en cuntildea Los segmentos a resecar se limitan por medio de la aplicacioacuten de dispositivos de grapado orientados en direcciones perpendiculares tratando de mantener la mayor cantidad de tejido sano
Insercioacuten de engrapadora lineal cortante a traveacutes de los orificios del tracto de la herida pulmonar penetrante
Figura 3- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales con fuga aeacuterea visible
Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales
Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
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The OBJECTIVES are
1) STOP HEMORRHAGE to correct underlying coagulopathy
2) MINIMIZE PERITONEAL CONTAMINATION and its secondary inflammatory response
3) ENCLOSE THE ABDOMINAL CONTENTS to protect viscera and minimize protein loss
4) The final objective of this damage-control phase is CLOSURE OF THE ABDOMINAL CAVITY
bullRequires robust MEDICAL SETTING
bullNeed system approach to deliver casualties to MOST CAPABLE FACILITIES
bullIsolated and far forward facilities can still benefit from these principles
AcidosisAcidosisBASE DEFICIT (BD) ge -15 identifies patients that require early
transfusion increased ICU days and risk for ARDS and MOF Ferrara A Mac Arthur J Wright H Hypothermia and Acidosis worsen coagulopathy in the patient requiring massive transfusion Ann J Surg 1990 160515-518
bull BD of ge -15 is strongly associated with the need for massive transfusion and mortality in patients
Rutherford EJ Morris JA Reed GW Hall KS Base deficit stratifies mortality and determines therapy J Trauma 1992 33417-23
bull Patients have an elevated BD before their blood pressure drops to classic ldquohypotensionrdquo levels
bull Acidosis contributes more to coagulopathy more than hypothermia (not reversible)
bull An initial INR ge 15 reliably predicts those who will require massive transfusion
Moore FA Nelson T Massive transfusion in trauma patients tissue hemoglobin oxygen saturation predicts poor outcom J Trauma 2008 Apr 64 (4)1010-23
bull Patients who have a significant injury present with a coagulopathy
bull Severity of injury and mortality is linearly associated with the degree of the initial coagulopathy
Coagulopathy
bull Although resuscitation strategies for severely injured patients who present WITH SHOCK have improved greatly the transfusions are associated with development of MOF and increased intensive care unit (ICU) admissions ICU and hospital length of stay and mortality
bull Malone DL Dunne J Tracy JK Putnam AT Scalea TM Napolitano LM Blood
transfusion independent of shock severity is associated with worse outcome in trauma J Trauma 2003 54898-905
bull Eastridge BJ Malone D Holcomb JB Early predictors of transfusion and mortality
after injury a review of the data-based literature J Trauma 2006 60S20-S25 bull Napolitano L Cumulative risks of early red blood cell transfusion J Trauma 2006
60S26-S34 bull Cotton BA Guy JS Morris JA Jr Abumrad NN The cellular metabolic and systemic
consequences of aggressive fluid resuscitation strategies Shock 2006 26115-121
Current transfusion practices and survival rates of massive transfusion patients vary widely among trauma centers Conventional guidelines may underestimate the optimal plasma and platelet to RBC ratios
Survival in patients is associated with increased plasma and platelet ratios Massive transfusion practice guidelines should aim for a111 ratio of plasma plateletsRBCs bullHolcomb et al Ann Surg 2008248447
Kaplan-Meier survival plot for the first 24 hours after admission for the 4 groups (high plasma (FFPH) or platelet (PltH) to RBC ratio 12 low plasma (FFPL) or platelet (PltL) to RBC ratio 12)
Statistical modeling indicated that a
clinical guideline with mean plasma
RBC ratio equal to 11 would
encompass 98 of patients within
the optimal 12 ratio
Hypotension A systolic blood pressure of 90 mm Hg or less is indicative casualties that have lost over 40 of their blood volume
(~2000 ml in an adult)
They have impending cardiovascular collapse and have significantly increased mortality
The most efficient solution for use in resuscitation is still under debate
Lactated Ringers (LR) and normal isotonic saline solution (NS) remain the
most commonly used isotonic fluids
Although colloid solutions including hyperosmolar colloid and hypertonic
electrolyte compounds have been approved for use as volume expanders
their administration is still under debate in the USA and Europe
Moore FA McKinley BA Moore EE Nathens AB West M Shapiro MB Bankey P Freeman B Harbrecht BG Johnson JL Minei JP Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core standard operating procedures for clinical care III Guidelines for shock resuscitation J Trauma 2006 6182-89 Spahn DR Cerny V Coats TJ Duranteau J Fernandez-Mondejar E Gordini G Stahel PF Hunt BJ Komadina R Neugebauer E Ozier Y Riddez L Schultz A Vincent JL Rossaint R Task Force for Advanced Bleeding Care in Trauma Management of bleeding following major trauma a European guideline Crit Care 2007 11R17
Experimental studies have revealed that resuscitation with NS in the setting of massive hemorrhage requires significantly greater volume and is associated with increased physiologic derangements (for example hyperchloremic acidosis and dilutional coagulopathy) and higher mortality as compared with LR Healey MA Davis RE Liu FC Loomis WH Hoyt DB Lactated ringers is superior to normal saline in a model of massive hemorrhage and resuscitation J Trauma 1998 45894-899 Todd SR Malinoski D Muller PJ Schreiber MA Lactated Ringers is superior to normal saline in the resuscitation of uncontrolled hemorrhagic shock J Trauma 2007 62636-639
Reported data from several studies conducted in critically ill patients have indicated that use of colloid solutions has a significant impact on hemorrhage hemostasis and inflammatory response Roberts I Alderson P Bunn F Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2004 CD000567 Vercueil A Grocott MP Mythen MG Physiology pharmacology and rationale for colloid administration for the maintenance of effective hemodynamic stability in critically ill patients Transfus Med Rev 2005 1993-109 Lee CC Chang IJ Yen ZS Effect of different resuscitation fluids on cytokine response in a rat model of hemorrhagic shock Shock 2005 24177-181
Early administration of blood is one potential treatment to decrease the
need for massive crystalloid solution in hemorrhagic shock however the
limited supply of stored blood and potential adverse effects make this
option logistically difficult and possibly harmful
West MA Sha piro MB Nathens AB Johnson JL Moore EE Minei JP Bankey PE Freeman B Harbrecht BG McKinley BA Moore FA Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core-standard operating procedures for clinical care IV Guidelines for transfusion in the trauma patient J Trauma 2006 61436-439
Moore FA McKinley BA Moore EE Nathens AB West M Shapiro MB Bankey P Freeman B Harbrecht BG Johnson JL Minei JP Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core standard operating procedures for clinical care III Guidelines for shock resuscitation J Trauma 2006 6182-89 Spahn DR Cerny V Coats TJ Duranteau J Fernandez-Mondejar E Gordini G Stahel PF Hunt BJ Komadina R Neugebauer E Ozier Y Riddez L Schultz A Vincent JL Rossaint R Task Force for Advanced Bleeding Care in Trauma Management of bleeding following major trauma a European guideline Crit Care 2007 11R17
Transfusion-related risks include possible development of MOF increased
ICU admissions and length of stay increased hospital length of stay and
mortality
Malone DL Dunne J Tracy JK Putnam AT Scalea TM Napolitano LM Blood transfusion independent of shock severity is associated with worse outcome in trauma J Trauma 2003 54898-905
Eastridge BJ Malone D Holcomb JB Early predictors of transfusion and mortality after injury a review of the data-based literature J Trauma 2006 60S20-S25
Napolitano L Cumulative risks of early red blood cell transfusion J Trauma 2006 60S26-S34
Cotton BA Guy JS Morris JA Jr Abumrad NN The cellular metabolic and systemic consequences of aggressive fluid resuscitation strategies Shock 2006 26115-121
uarr hemorrhage + excessive hemodilution due to
uarr Blood Presion darr blood viscosity darr hematocrit
darr clotting factor concentration
Risks of Aggressive Volume Resuscitation
rFVIIaThe use of rFVIIa was associated with improved early and late survival after severe trauma and massive transfusion
rFVIIa was not associated with increased risk of thrombotic events
The Effect of Recombinant Activated Factor VII on Mortality in Combat-Related Casualties With Severe Trauma and Massive Transfusion
bull Philip C Spinella MD Jeremy G Perkins MD Daniel F McLaughlin MD Sarah E Niles MD MPHKurt W Grathwohl MD Alec C Beekley MD Jose Salinas PhD Sumeru Mehta MD Charles E Wade PhDand John B Holcomb MD J of Trauma- Feb 2008bull Dutton et al J Trauma 200457709 Conclusion consider early use of FVIIa in any pt with uncontrolled hemorrhage who has not responded to surgery or blood component therapy
bull Each unit of blood product biologically active + elevates risk of infections + ARDS (SDRA)Chaiwat et al Anesthesiology 2009110351 n=14070 pts NSCOT database retrospective
bull Older blood association whith elevates infection LOS MOSF + death Weinberg et al J Trauma 200865279
TemperatureA temperature lt 96degF or 35degC is associated with an increase in mortality (cardiac arrest SRP higher abnormal plaquelet function) Burch J Denton J Noble R Physiologic rationale for abbreviated laparotomy Surg Clin North Am 1997 77779-82 Trauma patients that are hypothermic are NOT PERFUSING their tissue
The COAGULATION CASCADE is an enzymatic pathway that degrades with temperature and ceases at 92 FGregory JS Francbeum L Towsened MC Incidence and timing of hypothermia in trauma patients undergoing operations J Trauma 1991 31795-800 If the temperature is lower than 33 C the mortality is 100although Beilman and col think itacutes a significant factor for MODS but not for the mortalityBeilman GJ Blondet JJ Early hypothermia in severely injured trauma patients is a significant risk factor for multiple organ dysfunction syndrome but not mortality Ann Surg 2009 May249(5)845-50
Diagnosis done
Damage Control Resuscitation
1 Hypotensive resuscitation
2 Hemostatic resuscitation
Damage control philosophy can be extended to haemostatic resuscitation
Restoring normal coagulation Minimizing crystalloidTraditional resuscitation strategies dilute the already deficient coagulation factors and increase multiple organ failure
The aggressive hemostatic resuscitation should be combined with equally aggressive control of bleeding
Spahn DR Cerny V Management of bleeding following major trauma a European guidelineCrit Care 2007 11(1) R 17
WAIT AND SEE
SURGEON
ABDOMINAL PACKING is a lifesaving technique for temporary control of severe injury and it is used in damage control surgery schedule
Its possible too applying packs in organ-specific techniques (early abdominal packing)
The median survival of the 70 certainly superior to the obtainable survival with immediate surgical repairbullIMMEDIATE FAILURES are substantially due to bleeding especially in underpacking caseREMOTE FAILURES septic and bound at the time of stay (above the 72 hours) and associated by the coexistence of lesions in these situations is possible a MOF syndrome due to excessive intra-abdominal pressure (overpacking) or to an Abdominal Compartment Syndrome
Stagnitti F Bresadola L Calderale SM Coletti M Ribaldi S Salvi PF Schillaci F Abdominal packing indications and method Ann Ital Chir 2003 Sep-Oct74(5)535-42
Benavides C Garciacutea C Apablaza S Rubilar P Ricaurte F Perales C et al Empaquetamiento hepaacutetico permanente con malla de poliglactina en estallido hepaacutetico secundario a Siacutendrome de Hellp Rev Chil Cir 2004 56 275-278 De la Fuente M Mendoza VH Robledo-Oyarzun F Cierre Temporal de la pared abdominal con polietileno Cir Ciruj 2002 70157-63 Serna VH El Siacutendrome Compartamental Abdominal Tesis de Postgrado Meacutexico 2000
When skin approximation is
not possible a temporary silo
is constructed by suturing a 3-
L cystoscopy irrigation bag
(BOGOTAacute BAG) to the skin
edge with a continuous No 2
nylon suture
The method of closure depends on whether skin approximation produces excessive intra-abdominal hypertension
Towel-clip closure of the skin is preferred because it is quick and easy
The second phase is intra-operative reassessment for hemorrhage control 30 minutes after initial abdominal closure in the operating room focusing on restoration of the patients physiological status specifically reversing hypothermia and coagulopathy
WE CAN HEAR THE HEMORRHAGE
The abdomen is then reopened and assessed for adequacy of hemostasis and for existence of residual mechanical bleeding This practice has allowed surgeons to minimize both early return to the operating room for ongoing hemorrhage and the amount of packing necessary for hemostasis With bleeding effectively controlled the abdomen is reclosed
The patient is transferred to the ICU for continued physiologic restoration in the third phase
Once coagulopathy hypothermia and acidosis have been corrected the patient can be returned to the operating room for definitive management of the injuries in the fourth phase
48-72 h after first surgery
COMPLICATIONS OF DAMAGE CONTROL LAPAROTOMY
1) ACS Acute Compartmental Syndrome
2) ARDS Acute Respiratory Distress of the Adult
3) MOF Multiple organ failure
4) DEATH
ABDOMINAL COMPARTMENT SYNDROME is defined as an intra-abdominal pressure of greater than 20 cm H2O with evidence of impaired organ function ie elevated peak airway pressures (gt45 cm
H2O) oliguria (lt05 mLkg per hour) or cardiovascular dysfunction
(hypotension despite adequate volume resuscitation or if a pulmonary artery catheter is present oxygen delivery index [calculated as milliliters of oxygen per minute per meter squared] of 600) Intra-abdominal pressure was measured indirectly using an indwelling Foley catheter as previously described
Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13 Damage control surgery in the abdomen an approach for the management of severe injured patientsGermanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis NNuffield Department of Surgery John Radcliffe Hospital Oxford UK Curr Opin Crit Care 2006 Aug12(4)346-50 Damage-control laparotomy Lee JC Peitzman AB Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA
ABDOMINAL COMPARTMENT SYNDROME occurred in 17 (33) of
52 Patients undergoing damage-control laparotomy and was
associated with a much higher incidence of ARDS and MOF (71 vs
31 without ACS P = 02)
More importantly our study suggests that primary fascial closure at
the termination of the initial damage-control laparotomy contributes to
the development of ACS as well as subsequent organ failure
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal ypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
Mayberry JC Mullins RJ Crass RA Trunkey DD Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure Arch Surg 1997132957-962
bull MOF Multiple organ failure
Seems to be a major source of postinjury morbidity and the leading cause of in-hospital mortality despite more than 25 years of intense investigation
Eiseman B Beart R Norton L Multiple organ failure Surg Gynecol Obstet 1977144323-326
Bauer AE Durham R Faist E Systemic inflammatory response syndrome (SIRS) multiple organ dysfunction syndrome (MODS) multiple organ failure (MOF) are we winning the battle Shock 19981079-89
The current pathophysiologic model of MOF focuses on uncontrolled systemic
hyperinflammation as a unifying concept following a variety of insults
Moore FA Moore EE Evolving concepts in the pathogenesis of postinjury multiple organ failure Surg Clin North Am 199575257-277
Goris RJ te Boekhorst TP Nuytinck JK Gimbrere JS Multiple-organ failure generalized autodestructive inflammation Arch Surg 19851201109-1115
Nuytinck HK Offermans XJ Kubat K Goris JA Whole-body inflammation in trauma patients an autopsy study Arch Surg 19881231519-1524
Examples that improve the prognosis of MOF include damage control surgery recognition of abdominal compartment syndrome lung protective ventilation
strategies and tight glucose level control
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal hypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
The Acute Respiratory Distress Syndrome Network Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome N Engl J Med 20003421301-1308
Amato MB Barbas CS Medeiros DM et al Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome N Engl J Med 1998338347-354
Van den Berghe G Wouters P Weekers F et al Intensive insulin therapy in the critically ill patients N Engl J Med 20013451359-1367
The incidence of postinjury MOF has been reported to be between 7 and 66 with an associated mortality rate between 31 and 80
Fry DE Pearlstein L Fulton RL Polk HC Jr Multiple system organ failure the role of uncontrolled infection Arch Surg 1980115136-140
Regel G Lobenhoffer P Grotz M Pape HC Lehmann U Tscherne H Treatment results of patients with multiple trauma an analysis of 3406 cases treated between 1972 and 1991 at a German level I trauma center J Trauma 19953870-78
Sauaia A Moore FA Moore EE Norris JM Lezotte DC Hamman RF Multiple organ failure can be predicted as early as 12 hours after injury J Trauma 199845291-303
Nast-Kolb D Aufmkolk M Rucholtz S Obertacke U Waydhas C Multiple organ failure still a major cause of morbidity but not mortality in blunt multiple trauma J Trauma 200151835-842 Durham RM Moran JJ Mazuski JE Shapiro MJ Baue AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
It has been suggested that MOF is disappearing owing to advances in trauma and critical care
Levine JH Durham RM Moran J Bauer A Multiple organ failure is it disappearing World J Surg 199620471-473
Recent reports have not demonstrated a consistent change in either the incidence or the mortality rate associated with postinjury MOF Some groups have reported no change in the incidence but a decreased mortality while others have reported both decreased incidence and mortality compared with historical control subjects
Durham RM Moran JJ Mazuski JE Shapiro MJ Bauer AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
Regel G Grotz M Weltner T Sturm JA Tscherne H Pattern of organ failure following severe trauma World J Surg 199620422-429
Orthopaedic Trauma
Open pelvic fractures in addition to the pelvic ring injury are associated with hemorrhage and neurological insult visceral injuries are more common and a high rate of infection is seen Mortality of open pelvic fractures historically approached 50 Control of bleeding is the most important initial measure followed by debridement and packing of open wounds
Open book- widened symphysis pubis Dislocated Rt SI joint Vallier + Jenkins In Trauma Anesthesia 2008
Type 1 fractures occur due to anterior-posterior
compressioncan cause the symphysis pubis to ldquopoprdquo open leading to pubic rami or ldquoopen
bookrdquo fractures A lateral compression fracture type 2 or vertical sheer facture (Type 3) can
also lead to severe bleeding Into the pelvis Pelvic and acetabular surgery are major surgical interventions
Figura 1- Aplicacioacuten de la engrapadora para la reseccioacuten pulmonar en cuntildea Los segmentos a resecar se limitan por medio de la aplicacioacuten de dispositivos de grapado orientados en direcciones perpendiculares tratando de mantener la mayor cantidad de tejido sano
Insercioacuten de engrapadora lineal cortante a traveacutes de los orificios del tracto de la herida pulmonar penetrante
Figura 3- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales con fuga aeacuterea visible
Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales
Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
- Slide 1
- Slide 2
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
- Slide 10
- Slide 11
- Slide 12
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- Slide 31
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Slide 36
- Slide 37
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
bullRequires robust MEDICAL SETTING
bullNeed system approach to deliver casualties to MOST CAPABLE FACILITIES
bullIsolated and far forward facilities can still benefit from these principles
AcidosisAcidosisBASE DEFICIT (BD) ge -15 identifies patients that require early
transfusion increased ICU days and risk for ARDS and MOF Ferrara A Mac Arthur J Wright H Hypothermia and Acidosis worsen coagulopathy in the patient requiring massive transfusion Ann J Surg 1990 160515-518
bull BD of ge -15 is strongly associated with the need for massive transfusion and mortality in patients
Rutherford EJ Morris JA Reed GW Hall KS Base deficit stratifies mortality and determines therapy J Trauma 1992 33417-23
bull Patients have an elevated BD before their blood pressure drops to classic ldquohypotensionrdquo levels
bull Acidosis contributes more to coagulopathy more than hypothermia (not reversible)
bull An initial INR ge 15 reliably predicts those who will require massive transfusion
Moore FA Nelson T Massive transfusion in trauma patients tissue hemoglobin oxygen saturation predicts poor outcom J Trauma 2008 Apr 64 (4)1010-23
bull Patients who have a significant injury present with a coagulopathy
bull Severity of injury and mortality is linearly associated with the degree of the initial coagulopathy
Coagulopathy
bull Although resuscitation strategies for severely injured patients who present WITH SHOCK have improved greatly the transfusions are associated with development of MOF and increased intensive care unit (ICU) admissions ICU and hospital length of stay and mortality
bull Malone DL Dunne J Tracy JK Putnam AT Scalea TM Napolitano LM Blood
transfusion independent of shock severity is associated with worse outcome in trauma J Trauma 2003 54898-905
bull Eastridge BJ Malone D Holcomb JB Early predictors of transfusion and mortality
after injury a review of the data-based literature J Trauma 2006 60S20-S25 bull Napolitano L Cumulative risks of early red blood cell transfusion J Trauma 2006
60S26-S34 bull Cotton BA Guy JS Morris JA Jr Abumrad NN The cellular metabolic and systemic
consequences of aggressive fluid resuscitation strategies Shock 2006 26115-121
Current transfusion practices and survival rates of massive transfusion patients vary widely among trauma centers Conventional guidelines may underestimate the optimal plasma and platelet to RBC ratios
Survival in patients is associated with increased plasma and platelet ratios Massive transfusion practice guidelines should aim for a111 ratio of plasma plateletsRBCs bullHolcomb et al Ann Surg 2008248447
Kaplan-Meier survival plot for the first 24 hours after admission for the 4 groups (high plasma (FFPH) or platelet (PltH) to RBC ratio 12 low plasma (FFPL) or platelet (PltL) to RBC ratio 12)
Statistical modeling indicated that a
clinical guideline with mean plasma
RBC ratio equal to 11 would
encompass 98 of patients within
the optimal 12 ratio
Hypotension A systolic blood pressure of 90 mm Hg or less is indicative casualties that have lost over 40 of their blood volume
(~2000 ml in an adult)
They have impending cardiovascular collapse and have significantly increased mortality
The most efficient solution for use in resuscitation is still under debate
Lactated Ringers (LR) and normal isotonic saline solution (NS) remain the
most commonly used isotonic fluids
Although colloid solutions including hyperosmolar colloid and hypertonic
electrolyte compounds have been approved for use as volume expanders
their administration is still under debate in the USA and Europe
Moore FA McKinley BA Moore EE Nathens AB West M Shapiro MB Bankey P Freeman B Harbrecht BG Johnson JL Minei JP Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core standard operating procedures for clinical care III Guidelines for shock resuscitation J Trauma 2006 6182-89 Spahn DR Cerny V Coats TJ Duranteau J Fernandez-Mondejar E Gordini G Stahel PF Hunt BJ Komadina R Neugebauer E Ozier Y Riddez L Schultz A Vincent JL Rossaint R Task Force for Advanced Bleeding Care in Trauma Management of bleeding following major trauma a European guideline Crit Care 2007 11R17
Experimental studies have revealed that resuscitation with NS in the setting of massive hemorrhage requires significantly greater volume and is associated with increased physiologic derangements (for example hyperchloremic acidosis and dilutional coagulopathy) and higher mortality as compared with LR Healey MA Davis RE Liu FC Loomis WH Hoyt DB Lactated ringers is superior to normal saline in a model of massive hemorrhage and resuscitation J Trauma 1998 45894-899 Todd SR Malinoski D Muller PJ Schreiber MA Lactated Ringers is superior to normal saline in the resuscitation of uncontrolled hemorrhagic shock J Trauma 2007 62636-639
Reported data from several studies conducted in critically ill patients have indicated that use of colloid solutions has a significant impact on hemorrhage hemostasis and inflammatory response Roberts I Alderson P Bunn F Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2004 CD000567 Vercueil A Grocott MP Mythen MG Physiology pharmacology and rationale for colloid administration for the maintenance of effective hemodynamic stability in critically ill patients Transfus Med Rev 2005 1993-109 Lee CC Chang IJ Yen ZS Effect of different resuscitation fluids on cytokine response in a rat model of hemorrhagic shock Shock 2005 24177-181
Early administration of blood is one potential treatment to decrease the
need for massive crystalloid solution in hemorrhagic shock however the
limited supply of stored blood and potential adverse effects make this
option logistically difficult and possibly harmful
West MA Sha piro MB Nathens AB Johnson JL Moore EE Minei JP Bankey PE Freeman B Harbrecht BG McKinley BA Moore FA Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core-standard operating procedures for clinical care IV Guidelines for transfusion in the trauma patient J Trauma 2006 61436-439
Moore FA McKinley BA Moore EE Nathens AB West M Shapiro MB Bankey P Freeman B Harbrecht BG Johnson JL Minei JP Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core standard operating procedures for clinical care III Guidelines for shock resuscitation J Trauma 2006 6182-89 Spahn DR Cerny V Coats TJ Duranteau J Fernandez-Mondejar E Gordini G Stahel PF Hunt BJ Komadina R Neugebauer E Ozier Y Riddez L Schultz A Vincent JL Rossaint R Task Force for Advanced Bleeding Care in Trauma Management of bleeding following major trauma a European guideline Crit Care 2007 11R17
Transfusion-related risks include possible development of MOF increased
ICU admissions and length of stay increased hospital length of stay and
mortality
Malone DL Dunne J Tracy JK Putnam AT Scalea TM Napolitano LM Blood transfusion independent of shock severity is associated with worse outcome in trauma J Trauma 2003 54898-905
Eastridge BJ Malone D Holcomb JB Early predictors of transfusion and mortality after injury a review of the data-based literature J Trauma 2006 60S20-S25
Napolitano L Cumulative risks of early red blood cell transfusion J Trauma 2006 60S26-S34
Cotton BA Guy JS Morris JA Jr Abumrad NN The cellular metabolic and systemic consequences of aggressive fluid resuscitation strategies Shock 2006 26115-121
uarr hemorrhage + excessive hemodilution due to
uarr Blood Presion darr blood viscosity darr hematocrit
darr clotting factor concentration
Risks of Aggressive Volume Resuscitation
rFVIIaThe use of rFVIIa was associated with improved early and late survival after severe trauma and massive transfusion
rFVIIa was not associated with increased risk of thrombotic events
The Effect of Recombinant Activated Factor VII on Mortality in Combat-Related Casualties With Severe Trauma and Massive Transfusion
bull Philip C Spinella MD Jeremy G Perkins MD Daniel F McLaughlin MD Sarah E Niles MD MPHKurt W Grathwohl MD Alec C Beekley MD Jose Salinas PhD Sumeru Mehta MD Charles E Wade PhDand John B Holcomb MD J of Trauma- Feb 2008bull Dutton et al J Trauma 200457709 Conclusion consider early use of FVIIa in any pt with uncontrolled hemorrhage who has not responded to surgery or blood component therapy
bull Each unit of blood product biologically active + elevates risk of infections + ARDS (SDRA)Chaiwat et al Anesthesiology 2009110351 n=14070 pts NSCOT database retrospective
bull Older blood association whith elevates infection LOS MOSF + death Weinberg et al J Trauma 200865279
TemperatureA temperature lt 96degF or 35degC is associated with an increase in mortality (cardiac arrest SRP higher abnormal plaquelet function) Burch J Denton J Noble R Physiologic rationale for abbreviated laparotomy Surg Clin North Am 1997 77779-82 Trauma patients that are hypothermic are NOT PERFUSING their tissue
The COAGULATION CASCADE is an enzymatic pathway that degrades with temperature and ceases at 92 FGregory JS Francbeum L Towsened MC Incidence and timing of hypothermia in trauma patients undergoing operations J Trauma 1991 31795-800 If the temperature is lower than 33 C the mortality is 100although Beilman and col think itacutes a significant factor for MODS but not for the mortalityBeilman GJ Blondet JJ Early hypothermia in severely injured trauma patients is a significant risk factor for multiple organ dysfunction syndrome but not mortality Ann Surg 2009 May249(5)845-50
Diagnosis done
Damage Control Resuscitation
1 Hypotensive resuscitation
2 Hemostatic resuscitation
Damage control philosophy can be extended to haemostatic resuscitation
Restoring normal coagulation Minimizing crystalloidTraditional resuscitation strategies dilute the already deficient coagulation factors and increase multiple organ failure
The aggressive hemostatic resuscitation should be combined with equally aggressive control of bleeding
Spahn DR Cerny V Management of bleeding following major trauma a European guidelineCrit Care 2007 11(1) R 17
WAIT AND SEE
SURGEON
ABDOMINAL PACKING is a lifesaving technique for temporary control of severe injury and it is used in damage control surgery schedule
Its possible too applying packs in organ-specific techniques (early abdominal packing)
The median survival of the 70 certainly superior to the obtainable survival with immediate surgical repairbullIMMEDIATE FAILURES are substantially due to bleeding especially in underpacking caseREMOTE FAILURES septic and bound at the time of stay (above the 72 hours) and associated by the coexistence of lesions in these situations is possible a MOF syndrome due to excessive intra-abdominal pressure (overpacking) or to an Abdominal Compartment Syndrome
Stagnitti F Bresadola L Calderale SM Coletti M Ribaldi S Salvi PF Schillaci F Abdominal packing indications and method Ann Ital Chir 2003 Sep-Oct74(5)535-42
Benavides C Garciacutea C Apablaza S Rubilar P Ricaurte F Perales C et al Empaquetamiento hepaacutetico permanente con malla de poliglactina en estallido hepaacutetico secundario a Siacutendrome de Hellp Rev Chil Cir 2004 56 275-278 De la Fuente M Mendoza VH Robledo-Oyarzun F Cierre Temporal de la pared abdominal con polietileno Cir Ciruj 2002 70157-63 Serna VH El Siacutendrome Compartamental Abdominal Tesis de Postgrado Meacutexico 2000
When skin approximation is
not possible a temporary silo
is constructed by suturing a 3-
L cystoscopy irrigation bag
(BOGOTAacute BAG) to the skin
edge with a continuous No 2
nylon suture
The method of closure depends on whether skin approximation produces excessive intra-abdominal hypertension
Towel-clip closure of the skin is preferred because it is quick and easy
The second phase is intra-operative reassessment for hemorrhage control 30 minutes after initial abdominal closure in the operating room focusing on restoration of the patients physiological status specifically reversing hypothermia and coagulopathy
WE CAN HEAR THE HEMORRHAGE
The abdomen is then reopened and assessed for adequacy of hemostasis and for existence of residual mechanical bleeding This practice has allowed surgeons to minimize both early return to the operating room for ongoing hemorrhage and the amount of packing necessary for hemostasis With bleeding effectively controlled the abdomen is reclosed
The patient is transferred to the ICU for continued physiologic restoration in the third phase
Once coagulopathy hypothermia and acidosis have been corrected the patient can be returned to the operating room for definitive management of the injuries in the fourth phase
48-72 h after first surgery
COMPLICATIONS OF DAMAGE CONTROL LAPAROTOMY
1) ACS Acute Compartmental Syndrome
2) ARDS Acute Respiratory Distress of the Adult
3) MOF Multiple organ failure
4) DEATH
ABDOMINAL COMPARTMENT SYNDROME is defined as an intra-abdominal pressure of greater than 20 cm H2O with evidence of impaired organ function ie elevated peak airway pressures (gt45 cm
H2O) oliguria (lt05 mLkg per hour) or cardiovascular dysfunction
(hypotension despite adequate volume resuscitation or if a pulmonary artery catheter is present oxygen delivery index [calculated as milliliters of oxygen per minute per meter squared] of 600) Intra-abdominal pressure was measured indirectly using an indwelling Foley catheter as previously described
Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13 Damage control surgery in the abdomen an approach for the management of severe injured patientsGermanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis NNuffield Department of Surgery John Radcliffe Hospital Oxford UK Curr Opin Crit Care 2006 Aug12(4)346-50 Damage-control laparotomy Lee JC Peitzman AB Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA
ABDOMINAL COMPARTMENT SYNDROME occurred in 17 (33) of
52 Patients undergoing damage-control laparotomy and was
associated with a much higher incidence of ARDS and MOF (71 vs
31 without ACS P = 02)
More importantly our study suggests that primary fascial closure at
the termination of the initial damage-control laparotomy contributes to
the development of ACS as well as subsequent organ failure
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal ypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
Mayberry JC Mullins RJ Crass RA Trunkey DD Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure Arch Surg 1997132957-962
bull MOF Multiple organ failure
Seems to be a major source of postinjury morbidity and the leading cause of in-hospital mortality despite more than 25 years of intense investigation
Eiseman B Beart R Norton L Multiple organ failure Surg Gynecol Obstet 1977144323-326
Bauer AE Durham R Faist E Systemic inflammatory response syndrome (SIRS) multiple organ dysfunction syndrome (MODS) multiple organ failure (MOF) are we winning the battle Shock 19981079-89
The current pathophysiologic model of MOF focuses on uncontrolled systemic
hyperinflammation as a unifying concept following a variety of insults
Moore FA Moore EE Evolving concepts in the pathogenesis of postinjury multiple organ failure Surg Clin North Am 199575257-277
Goris RJ te Boekhorst TP Nuytinck JK Gimbrere JS Multiple-organ failure generalized autodestructive inflammation Arch Surg 19851201109-1115
Nuytinck HK Offermans XJ Kubat K Goris JA Whole-body inflammation in trauma patients an autopsy study Arch Surg 19881231519-1524
Examples that improve the prognosis of MOF include damage control surgery recognition of abdominal compartment syndrome lung protective ventilation
strategies and tight glucose level control
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal hypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
The Acute Respiratory Distress Syndrome Network Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome N Engl J Med 20003421301-1308
Amato MB Barbas CS Medeiros DM et al Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome N Engl J Med 1998338347-354
Van den Berghe G Wouters P Weekers F et al Intensive insulin therapy in the critically ill patients N Engl J Med 20013451359-1367
The incidence of postinjury MOF has been reported to be between 7 and 66 with an associated mortality rate between 31 and 80
Fry DE Pearlstein L Fulton RL Polk HC Jr Multiple system organ failure the role of uncontrolled infection Arch Surg 1980115136-140
Regel G Lobenhoffer P Grotz M Pape HC Lehmann U Tscherne H Treatment results of patients with multiple trauma an analysis of 3406 cases treated between 1972 and 1991 at a German level I trauma center J Trauma 19953870-78
Sauaia A Moore FA Moore EE Norris JM Lezotte DC Hamman RF Multiple organ failure can be predicted as early as 12 hours after injury J Trauma 199845291-303
Nast-Kolb D Aufmkolk M Rucholtz S Obertacke U Waydhas C Multiple organ failure still a major cause of morbidity but not mortality in blunt multiple trauma J Trauma 200151835-842 Durham RM Moran JJ Mazuski JE Shapiro MJ Baue AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
It has been suggested that MOF is disappearing owing to advances in trauma and critical care
Levine JH Durham RM Moran J Bauer A Multiple organ failure is it disappearing World J Surg 199620471-473
Recent reports have not demonstrated a consistent change in either the incidence or the mortality rate associated with postinjury MOF Some groups have reported no change in the incidence but a decreased mortality while others have reported both decreased incidence and mortality compared with historical control subjects
Durham RM Moran JJ Mazuski JE Shapiro MJ Bauer AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
Regel G Grotz M Weltner T Sturm JA Tscherne H Pattern of organ failure following severe trauma World J Surg 199620422-429
Orthopaedic Trauma
Open pelvic fractures in addition to the pelvic ring injury are associated with hemorrhage and neurological insult visceral injuries are more common and a high rate of infection is seen Mortality of open pelvic fractures historically approached 50 Control of bleeding is the most important initial measure followed by debridement and packing of open wounds
Open book- widened symphysis pubis Dislocated Rt SI joint Vallier + Jenkins In Trauma Anesthesia 2008
Type 1 fractures occur due to anterior-posterior
compressioncan cause the symphysis pubis to ldquopoprdquo open leading to pubic rami or ldquoopen
bookrdquo fractures A lateral compression fracture type 2 or vertical sheer facture (Type 3) can
also lead to severe bleeding Into the pelvis Pelvic and acetabular surgery are major surgical interventions
Figura 1- Aplicacioacuten de la engrapadora para la reseccioacuten pulmonar en cuntildea Los segmentos a resecar se limitan por medio de la aplicacioacuten de dispositivos de grapado orientados en direcciones perpendiculares tratando de mantener la mayor cantidad de tejido sano
Insercioacuten de engrapadora lineal cortante a traveacutes de los orificios del tracto de la herida pulmonar penetrante
Figura 3- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales con fuga aeacuterea visible
Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales
Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
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-
AcidosisAcidosisBASE DEFICIT (BD) ge -15 identifies patients that require early
transfusion increased ICU days and risk for ARDS and MOF Ferrara A Mac Arthur J Wright H Hypothermia and Acidosis worsen coagulopathy in the patient requiring massive transfusion Ann J Surg 1990 160515-518
bull BD of ge -15 is strongly associated with the need for massive transfusion and mortality in patients
Rutherford EJ Morris JA Reed GW Hall KS Base deficit stratifies mortality and determines therapy J Trauma 1992 33417-23
bull Patients have an elevated BD before their blood pressure drops to classic ldquohypotensionrdquo levels
bull Acidosis contributes more to coagulopathy more than hypothermia (not reversible)
bull An initial INR ge 15 reliably predicts those who will require massive transfusion
Moore FA Nelson T Massive transfusion in trauma patients tissue hemoglobin oxygen saturation predicts poor outcom J Trauma 2008 Apr 64 (4)1010-23
bull Patients who have a significant injury present with a coagulopathy
bull Severity of injury and mortality is linearly associated with the degree of the initial coagulopathy
Coagulopathy
bull Although resuscitation strategies for severely injured patients who present WITH SHOCK have improved greatly the transfusions are associated with development of MOF and increased intensive care unit (ICU) admissions ICU and hospital length of stay and mortality
bull Malone DL Dunne J Tracy JK Putnam AT Scalea TM Napolitano LM Blood
transfusion independent of shock severity is associated with worse outcome in trauma J Trauma 2003 54898-905
bull Eastridge BJ Malone D Holcomb JB Early predictors of transfusion and mortality
after injury a review of the data-based literature J Trauma 2006 60S20-S25 bull Napolitano L Cumulative risks of early red blood cell transfusion J Trauma 2006
60S26-S34 bull Cotton BA Guy JS Morris JA Jr Abumrad NN The cellular metabolic and systemic
consequences of aggressive fluid resuscitation strategies Shock 2006 26115-121
Current transfusion practices and survival rates of massive transfusion patients vary widely among trauma centers Conventional guidelines may underestimate the optimal plasma and platelet to RBC ratios
Survival in patients is associated with increased plasma and platelet ratios Massive transfusion practice guidelines should aim for a111 ratio of plasma plateletsRBCs bullHolcomb et al Ann Surg 2008248447
Kaplan-Meier survival plot for the first 24 hours after admission for the 4 groups (high plasma (FFPH) or platelet (PltH) to RBC ratio 12 low plasma (FFPL) or platelet (PltL) to RBC ratio 12)
Statistical modeling indicated that a
clinical guideline with mean plasma
RBC ratio equal to 11 would
encompass 98 of patients within
the optimal 12 ratio
Hypotension A systolic blood pressure of 90 mm Hg or less is indicative casualties that have lost over 40 of their blood volume
(~2000 ml in an adult)
They have impending cardiovascular collapse and have significantly increased mortality
The most efficient solution for use in resuscitation is still under debate
Lactated Ringers (LR) and normal isotonic saline solution (NS) remain the
most commonly used isotonic fluids
Although colloid solutions including hyperosmolar colloid and hypertonic
electrolyte compounds have been approved for use as volume expanders
their administration is still under debate in the USA and Europe
Moore FA McKinley BA Moore EE Nathens AB West M Shapiro MB Bankey P Freeman B Harbrecht BG Johnson JL Minei JP Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core standard operating procedures for clinical care III Guidelines for shock resuscitation J Trauma 2006 6182-89 Spahn DR Cerny V Coats TJ Duranteau J Fernandez-Mondejar E Gordini G Stahel PF Hunt BJ Komadina R Neugebauer E Ozier Y Riddez L Schultz A Vincent JL Rossaint R Task Force for Advanced Bleeding Care in Trauma Management of bleeding following major trauma a European guideline Crit Care 2007 11R17
Experimental studies have revealed that resuscitation with NS in the setting of massive hemorrhage requires significantly greater volume and is associated with increased physiologic derangements (for example hyperchloremic acidosis and dilutional coagulopathy) and higher mortality as compared with LR Healey MA Davis RE Liu FC Loomis WH Hoyt DB Lactated ringers is superior to normal saline in a model of massive hemorrhage and resuscitation J Trauma 1998 45894-899 Todd SR Malinoski D Muller PJ Schreiber MA Lactated Ringers is superior to normal saline in the resuscitation of uncontrolled hemorrhagic shock J Trauma 2007 62636-639
Reported data from several studies conducted in critically ill patients have indicated that use of colloid solutions has a significant impact on hemorrhage hemostasis and inflammatory response Roberts I Alderson P Bunn F Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2004 CD000567 Vercueil A Grocott MP Mythen MG Physiology pharmacology and rationale for colloid administration for the maintenance of effective hemodynamic stability in critically ill patients Transfus Med Rev 2005 1993-109 Lee CC Chang IJ Yen ZS Effect of different resuscitation fluids on cytokine response in a rat model of hemorrhagic shock Shock 2005 24177-181
Early administration of blood is one potential treatment to decrease the
need for massive crystalloid solution in hemorrhagic shock however the
limited supply of stored blood and potential adverse effects make this
option logistically difficult and possibly harmful
West MA Sha piro MB Nathens AB Johnson JL Moore EE Minei JP Bankey PE Freeman B Harbrecht BG McKinley BA Moore FA Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core-standard operating procedures for clinical care IV Guidelines for transfusion in the trauma patient J Trauma 2006 61436-439
Moore FA McKinley BA Moore EE Nathens AB West M Shapiro MB Bankey P Freeman B Harbrecht BG Johnson JL Minei JP Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core standard operating procedures for clinical care III Guidelines for shock resuscitation J Trauma 2006 6182-89 Spahn DR Cerny V Coats TJ Duranteau J Fernandez-Mondejar E Gordini G Stahel PF Hunt BJ Komadina R Neugebauer E Ozier Y Riddez L Schultz A Vincent JL Rossaint R Task Force for Advanced Bleeding Care in Trauma Management of bleeding following major trauma a European guideline Crit Care 2007 11R17
Transfusion-related risks include possible development of MOF increased
ICU admissions and length of stay increased hospital length of stay and
mortality
Malone DL Dunne J Tracy JK Putnam AT Scalea TM Napolitano LM Blood transfusion independent of shock severity is associated with worse outcome in trauma J Trauma 2003 54898-905
Eastridge BJ Malone D Holcomb JB Early predictors of transfusion and mortality after injury a review of the data-based literature J Trauma 2006 60S20-S25
Napolitano L Cumulative risks of early red blood cell transfusion J Trauma 2006 60S26-S34
Cotton BA Guy JS Morris JA Jr Abumrad NN The cellular metabolic and systemic consequences of aggressive fluid resuscitation strategies Shock 2006 26115-121
uarr hemorrhage + excessive hemodilution due to
uarr Blood Presion darr blood viscosity darr hematocrit
darr clotting factor concentration
Risks of Aggressive Volume Resuscitation
rFVIIaThe use of rFVIIa was associated with improved early and late survival after severe trauma and massive transfusion
rFVIIa was not associated with increased risk of thrombotic events
The Effect of Recombinant Activated Factor VII on Mortality in Combat-Related Casualties With Severe Trauma and Massive Transfusion
bull Philip C Spinella MD Jeremy G Perkins MD Daniel F McLaughlin MD Sarah E Niles MD MPHKurt W Grathwohl MD Alec C Beekley MD Jose Salinas PhD Sumeru Mehta MD Charles E Wade PhDand John B Holcomb MD J of Trauma- Feb 2008bull Dutton et al J Trauma 200457709 Conclusion consider early use of FVIIa in any pt with uncontrolled hemorrhage who has not responded to surgery or blood component therapy
bull Each unit of blood product biologically active + elevates risk of infections + ARDS (SDRA)Chaiwat et al Anesthesiology 2009110351 n=14070 pts NSCOT database retrospective
bull Older blood association whith elevates infection LOS MOSF + death Weinberg et al J Trauma 200865279
TemperatureA temperature lt 96degF or 35degC is associated with an increase in mortality (cardiac arrest SRP higher abnormal plaquelet function) Burch J Denton J Noble R Physiologic rationale for abbreviated laparotomy Surg Clin North Am 1997 77779-82 Trauma patients that are hypothermic are NOT PERFUSING their tissue
The COAGULATION CASCADE is an enzymatic pathway that degrades with temperature and ceases at 92 FGregory JS Francbeum L Towsened MC Incidence and timing of hypothermia in trauma patients undergoing operations J Trauma 1991 31795-800 If the temperature is lower than 33 C the mortality is 100although Beilman and col think itacutes a significant factor for MODS but not for the mortalityBeilman GJ Blondet JJ Early hypothermia in severely injured trauma patients is a significant risk factor for multiple organ dysfunction syndrome but not mortality Ann Surg 2009 May249(5)845-50
Diagnosis done
Damage Control Resuscitation
1 Hypotensive resuscitation
2 Hemostatic resuscitation
Damage control philosophy can be extended to haemostatic resuscitation
Restoring normal coagulation Minimizing crystalloidTraditional resuscitation strategies dilute the already deficient coagulation factors and increase multiple organ failure
The aggressive hemostatic resuscitation should be combined with equally aggressive control of bleeding
Spahn DR Cerny V Management of bleeding following major trauma a European guidelineCrit Care 2007 11(1) R 17
WAIT AND SEE
SURGEON
ABDOMINAL PACKING is a lifesaving technique for temporary control of severe injury and it is used in damage control surgery schedule
Its possible too applying packs in organ-specific techniques (early abdominal packing)
The median survival of the 70 certainly superior to the obtainable survival with immediate surgical repairbullIMMEDIATE FAILURES are substantially due to bleeding especially in underpacking caseREMOTE FAILURES septic and bound at the time of stay (above the 72 hours) and associated by the coexistence of lesions in these situations is possible a MOF syndrome due to excessive intra-abdominal pressure (overpacking) or to an Abdominal Compartment Syndrome
Stagnitti F Bresadola L Calderale SM Coletti M Ribaldi S Salvi PF Schillaci F Abdominal packing indications and method Ann Ital Chir 2003 Sep-Oct74(5)535-42
Benavides C Garciacutea C Apablaza S Rubilar P Ricaurte F Perales C et al Empaquetamiento hepaacutetico permanente con malla de poliglactina en estallido hepaacutetico secundario a Siacutendrome de Hellp Rev Chil Cir 2004 56 275-278 De la Fuente M Mendoza VH Robledo-Oyarzun F Cierre Temporal de la pared abdominal con polietileno Cir Ciruj 2002 70157-63 Serna VH El Siacutendrome Compartamental Abdominal Tesis de Postgrado Meacutexico 2000
When skin approximation is
not possible a temporary silo
is constructed by suturing a 3-
L cystoscopy irrigation bag
(BOGOTAacute BAG) to the skin
edge with a continuous No 2
nylon suture
The method of closure depends on whether skin approximation produces excessive intra-abdominal hypertension
Towel-clip closure of the skin is preferred because it is quick and easy
The second phase is intra-operative reassessment for hemorrhage control 30 minutes after initial abdominal closure in the operating room focusing on restoration of the patients physiological status specifically reversing hypothermia and coagulopathy
WE CAN HEAR THE HEMORRHAGE
The abdomen is then reopened and assessed for adequacy of hemostasis and for existence of residual mechanical bleeding This practice has allowed surgeons to minimize both early return to the operating room for ongoing hemorrhage and the amount of packing necessary for hemostasis With bleeding effectively controlled the abdomen is reclosed
The patient is transferred to the ICU for continued physiologic restoration in the third phase
Once coagulopathy hypothermia and acidosis have been corrected the patient can be returned to the operating room for definitive management of the injuries in the fourth phase
48-72 h after first surgery
COMPLICATIONS OF DAMAGE CONTROL LAPAROTOMY
1) ACS Acute Compartmental Syndrome
2) ARDS Acute Respiratory Distress of the Adult
3) MOF Multiple organ failure
4) DEATH
ABDOMINAL COMPARTMENT SYNDROME is defined as an intra-abdominal pressure of greater than 20 cm H2O with evidence of impaired organ function ie elevated peak airway pressures (gt45 cm
H2O) oliguria (lt05 mLkg per hour) or cardiovascular dysfunction
(hypotension despite adequate volume resuscitation or if a pulmonary artery catheter is present oxygen delivery index [calculated as milliliters of oxygen per minute per meter squared] of 600) Intra-abdominal pressure was measured indirectly using an indwelling Foley catheter as previously described
Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13 Damage control surgery in the abdomen an approach for the management of severe injured patientsGermanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis NNuffield Department of Surgery John Radcliffe Hospital Oxford UK Curr Opin Crit Care 2006 Aug12(4)346-50 Damage-control laparotomy Lee JC Peitzman AB Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA
ABDOMINAL COMPARTMENT SYNDROME occurred in 17 (33) of
52 Patients undergoing damage-control laparotomy and was
associated with a much higher incidence of ARDS and MOF (71 vs
31 without ACS P = 02)
More importantly our study suggests that primary fascial closure at
the termination of the initial damage-control laparotomy contributes to
the development of ACS as well as subsequent organ failure
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal ypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
Mayberry JC Mullins RJ Crass RA Trunkey DD Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure Arch Surg 1997132957-962
bull MOF Multiple organ failure
Seems to be a major source of postinjury morbidity and the leading cause of in-hospital mortality despite more than 25 years of intense investigation
Eiseman B Beart R Norton L Multiple organ failure Surg Gynecol Obstet 1977144323-326
Bauer AE Durham R Faist E Systemic inflammatory response syndrome (SIRS) multiple organ dysfunction syndrome (MODS) multiple organ failure (MOF) are we winning the battle Shock 19981079-89
The current pathophysiologic model of MOF focuses on uncontrolled systemic
hyperinflammation as a unifying concept following a variety of insults
Moore FA Moore EE Evolving concepts in the pathogenesis of postinjury multiple organ failure Surg Clin North Am 199575257-277
Goris RJ te Boekhorst TP Nuytinck JK Gimbrere JS Multiple-organ failure generalized autodestructive inflammation Arch Surg 19851201109-1115
Nuytinck HK Offermans XJ Kubat K Goris JA Whole-body inflammation in trauma patients an autopsy study Arch Surg 19881231519-1524
Examples that improve the prognosis of MOF include damage control surgery recognition of abdominal compartment syndrome lung protective ventilation
strategies and tight glucose level control
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal hypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
The Acute Respiratory Distress Syndrome Network Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome N Engl J Med 20003421301-1308
Amato MB Barbas CS Medeiros DM et al Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome N Engl J Med 1998338347-354
Van den Berghe G Wouters P Weekers F et al Intensive insulin therapy in the critically ill patients N Engl J Med 20013451359-1367
The incidence of postinjury MOF has been reported to be between 7 and 66 with an associated mortality rate between 31 and 80
Fry DE Pearlstein L Fulton RL Polk HC Jr Multiple system organ failure the role of uncontrolled infection Arch Surg 1980115136-140
Regel G Lobenhoffer P Grotz M Pape HC Lehmann U Tscherne H Treatment results of patients with multiple trauma an analysis of 3406 cases treated between 1972 and 1991 at a German level I trauma center J Trauma 19953870-78
Sauaia A Moore FA Moore EE Norris JM Lezotte DC Hamman RF Multiple organ failure can be predicted as early as 12 hours after injury J Trauma 199845291-303
Nast-Kolb D Aufmkolk M Rucholtz S Obertacke U Waydhas C Multiple organ failure still a major cause of morbidity but not mortality in blunt multiple trauma J Trauma 200151835-842 Durham RM Moran JJ Mazuski JE Shapiro MJ Baue AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
It has been suggested that MOF is disappearing owing to advances in trauma and critical care
Levine JH Durham RM Moran J Bauer A Multiple organ failure is it disappearing World J Surg 199620471-473
Recent reports have not demonstrated a consistent change in either the incidence or the mortality rate associated with postinjury MOF Some groups have reported no change in the incidence but a decreased mortality while others have reported both decreased incidence and mortality compared with historical control subjects
Durham RM Moran JJ Mazuski JE Shapiro MJ Bauer AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
Regel G Grotz M Weltner T Sturm JA Tscherne H Pattern of organ failure following severe trauma World J Surg 199620422-429
Orthopaedic Trauma
Open pelvic fractures in addition to the pelvic ring injury are associated with hemorrhage and neurological insult visceral injuries are more common and a high rate of infection is seen Mortality of open pelvic fractures historically approached 50 Control of bleeding is the most important initial measure followed by debridement and packing of open wounds
Open book- widened symphysis pubis Dislocated Rt SI joint Vallier + Jenkins In Trauma Anesthesia 2008
Type 1 fractures occur due to anterior-posterior
compressioncan cause the symphysis pubis to ldquopoprdquo open leading to pubic rami or ldquoopen
bookrdquo fractures A lateral compression fracture type 2 or vertical sheer facture (Type 3) can
also lead to severe bleeding Into the pelvis Pelvic and acetabular surgery are major surgical interventions
Figura 1- Aplicacioacuten de la engrapadora para la reseccioacuten pulmonar en cuntildea Los segmentos a resecar se limitan por medio de la aplicacioacuten de dispositivos de grapado orientados en direcciones perpendiculares tratando de mantener la mayor cantidad de tejido sano
Insercioacuten de engrapadora lineal cortante a traveacutes de los orificios del tracto de la herida pulmonar penetrante
Figura 3- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales con fuga aeacuterea visible
Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales
Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
- Slide 1
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-
bull An initial INR ge 15 reliably predicts those who will require massive transfusion
Moore FA Nelson T Massive transfusion in trauma patients tissue hemoglobin oxygen saturation predicts poor outcom J Trauma 2008 Apr 64 (4)1010-23
bull Patients who have a significant injury present with a coagulopathy
bull Severity of injury and mortality is linearly associated with the degree of the initial coagulopathy
Coagulopathy
bull Although resuscitation strategies for severely injured patients who present WITH SHOCK have improved greatly the transfusions are associated with development of MOF and increased intensive care unit (ICU) admissions ICU and hospital length of stay and mortality
bull Malone DL Dunne J Tracy JK Putnam AT Scalea TM Napolitano LM Blood
transfusion independent of shock severity is associated with worse outcome in trauma J Trauma 2003 54898-905
bull Eastridge BJ Malone D Holcomb JB Early predictors of transfusion and mortality
after injury a review of the data-based literature J Trauma 2006 60S20-S25 bull Napolitano L Cumulative risks of early red blood cell transfusion J Trauma 2006
60S26-S34 bull Cotton BA Guy JS Morris JA Jr Abumrad NN The cellular metabolic and systemic
consequences of aggressive fluid resuscitation strategies Shock 2006 26115-121
Current transfusion practices and survival rates of massive transfusion patients vary widely among trauma centers Conventional guidelines may underestimate the optimal plasma and platelet to RBC ratios
Survival in patients is associated with increased plasma and platelet ratios Massive transfusion practice guidelines should aim for a111 ratio of plasma plateletsRBCs bullHolcomb et al Ann Surg 2008248447
Kaplan-Meier survival plot for the first 24 hours after admission for the 4 groups (high plasma (FFPH) or platelet (PltH) to RBC ratio 12 low plasma (FFPL) or platelet (PltL) to RBC ratio 12)
Statistical modeling indicated that a
clinical guideline with mean plasma
RBC ratio equal to 11 would
encompass 98 of patients within
the optimal 12 ratio
Hypotension A systolic blood pressure of 90 mm Hg or less is indicative casualties that have lost over 40 of their blood volume
(~2000 ml in an adult)
They have impending cardiovascular collapse and have significantly increased mortality
The most efficient solution for use in resuscitation is still under debate
Lactated Ringers (LR) and normal isotonic saline solution (NS) remain the
most commonly used isotonic fluids
Although colloid solutions including hyperosmolar colloid and hypertonic
electrolyte compounds have been approved for use as volume expanders
their administration is still under debate in the USA and Europe
Moore FA McKinley BA Moore EE Nathens AB West M Shapiro MB Bankey P Freeman B Harbrecht BG Johnson JL Minei JP Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core standard operating procedures for clinical care III Guidelines for shock resuscitation J Trauma 2006 6182-89 Spahn DR Cerny V Coats TJ Duranteau J Fernandez-Mondejar E Gordini G Stahel PF Hunt BJ Komadina R Neugebauer E Ozier Y Riddez L Schultz A Vincent JL Rossaint R Task Force for Advanced Bleeding Care in Trauma Management of bleeding following major trauma a European guideline Crit Care 2007 11R17
Experimental studies have revealed that resuscitation with NS in the setting of massive hemorrhage requires significantly greater volume and is associated with increased physiologic derangements (for example hyperchloremic acidosis and dilutional coagulopathy) and higher mortality as compared with LR Healey MA Davis RE Liu FC Loomis WH Hoyt DB Lactated ringers is superior to normal saline in a model of massive hemorrhage and resuscitation J Trauma 1998 45894-899 Todd SR Malinoski D Muller PJ Schreiber MA Lactated Ringers is superior to normal saline in the resuscitation of uncontrolled hemorrhagic shock J Trauma 2007 62636-639
Reported data from several studies conducted in critically ill patients have indicated that use of colloid solutions has a significant impact on hemorrhage hemostasis and inflammatory response Roberts I Alderson P Bunn F Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2004 CD000567 Vercueil A Grocott MP Mythen MG Physiology pharmacology and rationale for colloid administration for the maintenance of effective hemodynamic stability in critically ill patients Transfus Med Rev 2005 1993-109 Lee CC Chang IJ Yen ZS Effect of different resuscitation fluids on cytokine response in a rat model of hemorrhagic shock Shock 2005 24177-181
Early administration of blood is one potential treatment to decrease the
need for massive crystalloid solution in hemorrhagic shock however the
limited supply of stored blood and potential adverse effects make this
option logistically difficult and possibly harmful
West MA Sha piro MB Nathens AB Johnson JL Moore EE Minei JP Bankey PE Freeman B Harbrecht BG McKinley BA Moore FA Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core-standard operating procedures for clinical care IV Guidelines for transfusion in the trauma patient J Trauma 2006 61436-439
Moore FA McKinley BA Moore EE Nathens AB West M Shapiro MB Bankey P Freeman B Harbrecht BG Johnson JL Minei JP Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core standard operating procedures for clinical care III Guidelines for shock resuscitation J Trauma 2006 6182-89 Spahn DR Cerny V Coats TJ Duranteau J Fernandez-Mondejar E Gordini G Stahel PF Hunt BJ Komadina R Neugebauer E Ozier Y Riddez L Schultz A Vincent JL Rossaint R Task Force for Advanced Bleeding Care in Trauma Management of bleeding following major trauma a European guideline Crit Care 2007 11R17
Transfusion-related risks include possible development of MOF increased
ICU admissions and length of stay increased hospital length of stay and
mortality
Malone DL Dunne J Tracy JK Putnam AT Scalea TM Napolitano LM Blood transfusion independent of shock severity is associated with worse outcome in trauma J Trauma 2003 54898-905
Eastridge BJ Malone D Holcomb JB Early predictors of transfusion and mortality after injury a review of the data-based literature J Trauma 2006 60S20-S25
Napolitano L Cumulative risks of early red blood cell transfusion J Trauma 2006 60S26-S34
Cotton BA Guy JS Morris JA Jr Abumrad NN The cellular metabolic and systemic consequences of aggressive fluid resuscitation strategies Shock 2006 26115-121
uarr hemorrhage + excessive hemodilution due to
uarr Blood Presion darr blood viscosity darr hematocrit
darr clotting factor concentration
Risks of Aggressive Volume Resuscitation
rFVIIaThe use of rFVIIa was associated with improved early and late survival after severe trauma and massive transfusion
rFVIIa was not associated with increased risk of thrombotic events
The Effect of Recombinant Activated Factor VII on Mortality in Combat-Related Casualties With Severe Trauma and Massive Transfusion
bull Philip C Spinella MD Jeremy G Perkins MD Daniel F McLaughlin MD Sarah E Niles MD MPHKurt W Grathwohl MD Alec C Beekley MD Jose Salinas PhD Sumeru Mehta MD Charles E Wade PhDand John B Holcomb MD J of Trauma- Feb 2008bull Dutton et al J Trauma 200457709 Conclusion consider early use of FVIIa in any pt with uncontrolled hemorrhage who has not responded to surgery or blood component therapy
bull Each unit of blood product biologically active + elevates risk of infections + ARDS (SDRA)Chaiwat et al Anesthesiology 2009110351 n=14070 pts NSCOT database retrospective
bull Older blood association whith elevates infection LOS MOSF + death Weinberg et al J Trauma 200865279
TemperatureA temperature lt 96degF or 35degC is associated with an increase in mortality (cardiac arrest SRP higher abnormal plaquelet function) Burch J Denton J Noble R Physiologic rationale for abbreviated laparotomy Surg Clin North Am 1997 77779-82 Trauma patients that are hypothermic are NOT PERFUSING their tissue
The COAGULATION CASCADE is an enzymatic pathway that degrades with temperature and ceases at 92 FGregory JS Francbeum L Towsened MC Incidence and timing of hypothermia in trauma patients undergoing operations J Trauma 1991 31795-800 If the temperature is lower than 33 C the mortality is 100although Beilman and col think itacutes a significant factor for MODS but not for the mortalityBeilman GJ Blondet JJ Early hypothermia in severely injured trauma patients is a significant risk factor for multiple organ dysfunction syndrome but not mortality Ann Surg 2009 May249(5)845-50
Diagnosis done
Damage Control Resuscitation
1 Hypotensive resuscitation
2 Hemostatic resuscitation
Damage control philosophy can be extended to haemostatic resuscitation
Restoring normal coagulation Minimizing crystalloidTraditional resuscitation strategies dilute the already deficient coagulation factors and increase multiple organ failure
The aggressive hemostatic resuscitation should be combined with equally aggressive control of bleeding
Spahn DR Cerny V Management of bleeding following major trauma a European guidelineCrit Care 2007 11(1) R 17
WAIT AND SEE
SURGEON
ABDOMINAL PACKING is a lifesaving technique for temporary control of severe injury and it is used in damage control surgery schedule
Its possible too applying packs in organ-specific techniques (early abdominal packing)
The median survival of the 70 certainly superior to the obtainable survival with immediate surgical repairbullIMMEDIATE FAILURES are substantially due to bleeding especially in underpacking caseREMOTE FAILURES septic and bound at the time of stay (above the 72 hours) and associated by the coexistence of lesions in these situations is possible a MOF syndrome due to excessive intra-abdominal pressure (overpacking) or to an Abdominal Compartment Syndrome
Stagnitti F Bresadola L Calderale SM Coletti M Ribaldi S Salvi PF Schillaci F Abdominal packing indications and method Ann Ital Chir 2003 Sep-Oct74(5)535-42
Benavides C Garciacutea C Apablaza S Rubilar P Ricaurte F Perales C et al Empaquetamiento hepaacutetico permanente con malla de poliglactina en estallido hepaacutetico secundario a Siacutendrome de Hellp Rev Chil Cir 2004 56 275-278 De la Fuente M Mendoza VH Robledo-Oyarzun F Cierre Temporal de la pared abdominal con polietileno Cir Ciruj 2002 70157-63 Serna VH El Siacutendrome Compartamental Abdominal Tesis de Postgrado Meacutexico 2000
When skin approximation is
not possible a temporary silo
is constructed by suturing a 3-
L cystoscopy irrigation bag
(BOGOTAacute BAG) to the skin
edge with a continuous No 2
nylon suture
The method of closure depends on whether skin approximation produces excessive intra-abdominal hypertension
Towel-clip closure of the skin is preferred because it is quick and easy
The second phase is intra-operative reassessment for hemorrhage control 30 minutes after initial abdominal closure in the operating room focusing on restoration of the patients physiological status specifically reversing hypothermia and coagulopathy
WE CAN HEAR THE HEMORRHAGE
The abdomen is then reopened and assessed for adequacy of hemostasis and for existence of residual mechanical bleeding This practice has allowed surgeons to minimize both early return to the operating room for ongoing hemorrhage and the amount of packing necessary for hemostasis With bleeding effectively controlled the abdomen is reclosed
The patient is transferred to the ICU for continued physiologic restoration in the third phase
Once coagulopathy hypothermia and acidosis have been corrected the patient can be returned to the operating room for definitive management of the injuries in the fourth phase
48-72 h after first surgery
COMPLICATIONS OF DAMAGE CONTROL LAPAROTOMY
1) ACS Acute Compartmental Syndrome
2) ARDS Acute Respiratory Distress of the Adult
3) MOF Multiple organ failure
4) DEATH
ABDOMINAL COMPARTMENT SYNDROME is defined as an intra-abdominal pressure of greater than 20 cm H2O with evidence of impaired organ function ie elevated peak airway pressures (gt45 cm
H2O) oliguria (lt05 mLkg per hour) or cardiovascular dysfunction
(hypotension despite adequate volume resuscitation or if a pulmonary artery catheter is present oxygen delivery index [calculated as milliliters of oxygen per minute per meter squared] of 600) Intra-abdominal pressure was measured indirectly using an indwelling Foley catheter as previously described
Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13 Damage control surgery in the abdomen an approach for the management of severe injured patientsGermanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis NNuffield Department of Surgery John Radcliffe Hospital Oxford UK Curr Opin Crit Care 2006 Aug12(4)346-50 Damage-control laparotomy Lee JC Peitzman AB Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA
ABDOMINAL COMPARTMENT SYNDROME occurred in 17 (33) of
52 Patients undergoing damage-control laparotomy and was
associated with a much higher incidence of ARDS and MOF (71 vs
31 without ACS P = 02)
More importantly our study suggests that primary fascial closure at
the termination of the initial damage-control laparotomy contributes to
the development of ACS as well as subsequent organ failure
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal ypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
Mayberry JC Mullins RJ Crass RA Trunkey DD Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure Arch Surg 1997132957-962
bull MOF Multiple organ failure
Seems to be a major source of postinjury morbidity and the leading cause of in-hospital mortality despite more than 25 years of intense investigation
Eiseman B Beart R Norton L Multiple organ failure Surg Gynecol Obstet 1977144323-326
Bauer AE Durham R Faist E Systemic inflammatory response syndrome (SIRS) multiple organ dysfunction syndrome (MODS) multiple organ failure (MOF) are we winning the battle Shock 19981079-89
The current pathophysiologic model of MOF focuses on uncontrolled systemic
hyperinflammation as a unifying concept following a variety of insults
Moore FA Moore EE Evolving concepts in the pathogenesis of postinjury multiple organ failure Surg Clin North Am 199575257-277
Goris RJ te Boekhorst TP Nuytinck JK Gimbrere JS Multiple-organ failure generalized autodestructive inflammation Arch Surg 19851201109-1115
Nuytinck HK Offermans XJ Kubat K Goris JA Whole-body inflammation in trauma patients an autopsy study Arch Surg 19881231519-1524
Examples that improve the prognosis of MOF include damage control surgery recognition of abdominal compartment syndrome lung protective ventilation
strategies and tight glucose level control
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal hypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
The Acute Respiratory Distress Syndrome Network Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome N Engl J Med 20003421301-1308
Amato MB Barbas CS Medeiros DM et al Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome N Engl J Med 1998338347-354
Van den Berghe G Wouters P Weekers F et al Intensive insulin therapy in the critically ill patients N Engl J Med 20013451359-1367
The incidence of postinjury MOF has been reported to be between 7 and 66 with an associated mortality rate between 31 and 80
Fry DE Pearlstein L Fulton RL Polk HC Jr Multiple system organ failure the role of uncontrolled infection Arch Surg 1980115136-140
Regel G Lobenhoffer P Grotz M Pape HC Lehmann U Tscherne H Treatment results of patients with multiple trauma an analysis of 3406 cases treated between 1972 and 1991 at a German level I trauma center J Trauma 19953870-78
Sauaia A Moore FA Moore EE Norris JM Lezotte DC Hamman RF Multiple organ failure can be predicted as early as 12 hours after injury J Trauma 199845291-303
Nast-Kolb D Aufmkolk M Rucholtz S Obertacke U Waydhas C Multiple organ failure still a major cause of morbidity but not mortality in blunt multiple trauma J Trauma 200151835-842 Durham RM Moran JJ Mazuski JE Shapiro MJ Baue AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
It has been suggested that MOF is disappearing owing to advances in trauma and critical care
Levine JH Durham RM Moran J Bauer A Multiple organ failure is it disappearing World J Surg 199620471-473
Recent reports have not demonstrated a consistent change in either the incidence or the mortality rate associated with postinjury MOF Some groups have reported no change in the incidence but a decreased mortality while others have reported both decreased incidence and mortality compared with historical control subjects
Durham RM Moran JJ Mazuski JE Shapiro MJ Bauer AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
Regel G Grotz M Weltner T Sturm JA Tscherne H Pattern of organ failure following severe trauma World J Surg 199620422-429
Orthopaedic Trauma
Open pelvic fractures in addition to the pelvic ring injury are associated with hemorrhage and neurological insult visceral injuries are more common and a high rate of infection is seen Mortality of open pelvic fractures historically approached 50 Control of bleeding is the most important initial measure followed by debridement and packing of open wounds
Open book- widened symphysis pubis Dislocated Rt SI joint Vallier + Jenkins In Trauma Anesthesia 2008
Type 1 fractures occur due to anterior-posterior
compressioncan cause the symphysis pubis to ldquopoprdquo open leading to pubic rami or ldquoopen
bookrdquo fractures A lateral compression fracture type 2 or vertical sheer facture (Type 3) can
also lead to severe bleeding Into the pelvis Pelvic and acetabular surgery are major surgical interventions
Figura 1- Aplicacioacuten de la engrapadora para la reseccioacuten pulmonar en cuntildea Los segmentos a resecar se limitan por medio de la aplicacioacuten de dispositivos de grapado orientados en direcciones perpendiculares tratando de mantener la mayor cantidad de tejido sano
Insercioacuten de engrapadora lineal cortante a traveacutes de los orificios del tracto de la herida pulmonar penetrante
Figura 3- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales con fuga aeacuterea visible
Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales
Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
- Slide 1
- Slide 2
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
- Slide 10
- Slide 11
- Slide 12
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- Slide 31
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Slide 36
- Slide 37
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
bull Although resuscitation strategies for severely injured patients who present WITH SHOCK have improved greatly the transfusions are associated with development of MOF and increased intensive care unit (ICU) admissions ICU and hospital length of stay and mortality
bull Malone DL Dunne J Tracy JK Putnam AT Scalea TM Napolitano LM Blood
transfusion independent of shock severity is associated with worse outcome in trauma J Trauma 2003 54898-905
bull Eastridge BJ Malone D Holcomb JB Early predictors of transfusion and mortality
after injury a review of the data-based literature J Trauma 2006 60S20-S25 bull Napolitano L Cumulative risks of early red blood cell transfusion J Trauma 2006
60S26-S34 bull Cotton BA Guy JS Morris JA Jr Abumrad NN The cellular metabolic and systemic
consequences of aggressive fluid resuscitation strategies Shock 2006 26115-121
Current transfusion practices and survival rates of massive transfusion patients vary widely among trauma centers Conventional guidelines may underestimate the optimal plasma and platelet to RBC ratios
Survival in patients is associated with increased plasma and platelet ratios Massive transfusion practice guidelines should aim for a111 ratio of plasma plateletsRBCs bullHolcomb et al Ann Surg 2008248447
Kaplan-Meier survival plot for the first 24 hours after admission for the 4 groups (high plasma (FFPH) or platelet (PltH) to RBC ratio 12 low plasma (FFPL) or platelet (PltL) to RBC ratio 12)
Statistical modeling indicated that a
clinical guideline with mean plasma
RBC ratio equal to 11 would
encompass 98 of patients within
the optimal 12 ratio
Hypotension A systolic blood pressure of 90 mm Hg or less is indicative casualties that have lost over 40 of their blood volume
(~2000 ml in an adult)
They have impending cardiovascular collapse and have significantly increased mortality
The most efficient solution for use in resuscitation is still under debate
Lactated Ringers (LR) and normal isotonic saline solution (NS) remain the
most commonly used isotonic fluids
Although colloid solutions including hyperosmolar colloid and hypertonic
electrolyte compounds have been approved for use as volume expanders
their administration is still under debate in the USA and Europe
Moore FA McKinley BA Moore EE Nathens AB West M Shapiro MB Bankey P Freeman B Harbrecht BG Johnson JL Minei JP Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core standard operating procedures for clinical care III Guidelines for shock resuscitation J Trauma 2006 6182-89 Spahn DR Cerny V Coats TJ Duranteau J Fernandez-Mondejar E Gordini G Stahel PF Hunt BJ Komadina R Neugebauer E Ozier Y Riddez L Schultz A Vincent JL Rossaint R Task Force for Advanced Bleeding Care in Trauma Management of bleeding following major trauma a European guideline Crit Care 2007 11R17
Experimental studies have revealed that resuscitation with NS in the setting of massive hemorrhage requires significantly greater volume and is associated with increased physiologic derangements (for example hyperchloremic acidosis and dilutional coagulopathy) and higher mortality as compared with LR Healey MA Davis RE Liu FC Loomis WH Hoyt DB Lactated ringers is superior to normal saline in a model of massive hemorrhage and resuscitation J Trauma 1998 45894-899 Todd SR Malinoski D Muller PJ Schreiber MA Lactated Ringers is superior to normal saline in the resuscitation of uncontrolled hemorrhagic shock J Trauma 2007 62636-639
Reported data from several studies conducted in critically ill patients have indicated that use of colloid solutions has a significant impact on hemorrhage hemostasis and inflammatory response Roberts I Alderson P Bunn F Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2004 CD000567 Vercueil A Grocott MP Mythen MG Physiology pharmacology and rationale for colloid administration for the maintenance of effective hemodynamic stability in critically ill patients Transfus Med Rev 2005 1993-109 Lee CC Chang IJ Yen ZS Effect of different resuscitation fluids on cytokine response in a rat model of hemorrhagic shock Shock 2005 24177-181
Early administration of blood is one potential treatment to decrease the
need for massive crystalloid solution in hemorrhagic shock however the
limited supply of stored blood and potential adverse effects make this
option logistically difficult and possibly harmful
West MA Sha piro MB Nathens AB Johnson JL Moore EE Minei JP Bankey PE Freeman B Harbrecht BG McKinley BA Moore FA Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core-standard operating procedures for clinical care IV Guidelines for transfusion in the trauma patient J Trauma 2006 61436-439
Moore FA McKinley BA Moore EE Nathens AB West M Shapiro MB Bankey P Freeman B Harbrecht BG Johnson JL Minei JP Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core standard operating procedures for clinical care III Guidelines for shock resuscitation J Trauma 2006 6182-89 Spahn DR Cerny V Coats TJ Duranteau J Fernandez-Mondejar E Gordini G Stahel PF Hunt BJ Komadina R Neugebauer E Ozier Y Riddez L Schultz A Vincent JL Rossaint R Task Force for Advanced Bleeding Care in Trauma Management of bleeding following major trauma a European guideline Crit Care 2007 11R17
Transfusion-related risks include possible development of MOF increased
ICU admissions and length of stay increased hospital length of stay and
mortality
Malone DL Dunne J Tracy JK Putnam AT Scalea TM Napolitano LM Blood transfusion independent of shock severity is associated with worse outcome in trauma J Trauma 2003 54898-905
Eastridge BJ Malone D Holcomb JB Early predictors of transfusion and mortality after injury a review of the data-based literature J Trauma 2006 60S20-S25
Napolitano L Cumulative risks of early red blood cell transfusion J Trauma 2006 60S26-S34
Cotton BA Guy JS Morris JA Jr Abumrad NN The cellular metabolic and systemic consequences of aggressive fluid resuscitation strategies Shock 2006 26115-121
uarr hemorrhage + excessive hemodilution due to
uarr Blood Presion darr blood viscosity darr hematocrit
darr clotting factor concentration
Risks of Aggressive Volume Resuscitation
rFVIIaThe use of rFVIIa was associated with improved early and late survival after severe trauma and massive transfusion
rFVIIa was not associated with increased risk of thrombotic events
The Effect of Recombinant Activated Factor VII on Mortality in Combat-Related Casualties With Severe Trauma and Massive Transfusion
bull Philip C Spinella MD Jeremy G Perkins MD Daniel F McLaughlin MD Sarah E Niles MD MPHKurt W Grathwohl MD Alec C Beekley MD Jose Salinas PhD Sumeru Mehta MD Charles E Wade PhDand John B Holcomb MD J of Trauma- Feb 2008bull Dutton et al J Trauma 200457709 Conclusion consider early use of FVIIa in any pt with uncontrolled hemorrhage who has not responded to surgery or blood component therapy
bull Each unit of blood product biologically active + elevates risk of infections + ARDS (SDRA)Chaiwat et al Anesthesiology 2009110351 n=14070 pts NSCOT database retrospective
bull Older blood association whith elevates infection LOS MOSF + death Weinberg et al J Trauma 200865279
TemperatureA temperature lt 96degF or 35degC is associated with an increase in mortality (cardiac arrest SRP higher abnormal plaquelet function) Burch J Denton J Noble R Physiologic rationale for abbreviated laparotomy Surg Clin North Am 1997 77779-82 Trauma patients that are hypothermic are NOT PERFUSING their tissue
The COAGULATION CASCADE is an enzymatic pathway that degrades with temperature and ceases at 92 FGregory JS Francbeum L Towsened MC Incidence and timing of hypothermia in trauma patients undergoing operations J Trauma 1991 31795-800 If the temperature is lower than 33 C the mortality is 100although Beilman and col think itacutes a significant factor for MODS but not for the mortalityBeilman GJ Blondet JJ Early hypothermia in severely injured trauma patients is a significant risk factor for multiple organ dysfunction syndrome but not mortality Ann Surg 2009 May249(5)845-50
Diagnosis done
Damage Control Resuscitation
1 Hypotensive resuscitation
2 Hemostatic resuscitation
Damage control philosophy can be extended to haemostatic resuscitation
Restoring normal coagulation Minimizing crystalloidTraditional resuscitation strategies dilute the already deficient coagulation factors and increase multiple organ failure
The aggressive hemostatic resuscitation should be combined with equally aggressive control of bleeding
Spahn DR Cerny V Management of bleeding following major trauma a European guidelineCrit Care 2007 11(1) R 17
WAIT AND SEE
SURGEON
ABDOMINAL PACKING is a lifesaving technique for temporary control of severe injury and it is used in damage control surgery schedule
Its possible too applying packs in organ-specific techniques (early abdominal packing)
The median survival of the 70 certainly superior to the obtainable survival with immediate surgical repairbullIMMEDIATE FAILURES are substantially due to bleeding especially in underpacking caseREMOTE FAILURES septic and bound at the time of stay (above the 72 hours) and associated by the coexistence of lesions in these situations is possible a MOF syndrome due to excessive intra-abdominal pressure (overpacking) or to an Abdominal Compartment Syndrome
Stagnitti F Bresadola L Calderale SM Coletti M Ribaldi S Salvi PF Schillaci F Abdominal packing indications and method Ann Ital Chir 2003 Sep-Oct74(5)535-42
Benavides C Garciacutea C Apablaza S Rubilar P Ricaurte F Perales C et al Empaquetamiento hepaacutetico permanente con malla de poliglactina en estallido hepaacutetico secundario a Siacutendrome de Hellp Rev Chil Cir 2004 56 275-278 De la Fuente M Mendoza VH Robledo-Oyarzun F Cierre Temporal de la pared abdominal con polietileno Cir Ciruj 2002 70157-63 Serna VH El Siacutendrome Compartamental Abdominal Tesis de Postgrado Meacutexico 2000
When skin approximation is
not possible a temporary silo
is constructed by suturing a 3-
L cystoscopy irrigation bag
(BOGOTAacute BAG) to the skin
edge with a continuous No 2
nylon suture
The method of closure depends on whether skin approximation produces excessive intra-abdominal hypertension
Towel-clip closure of the skin is preferred because it is quick and easy
The second phase is intra-operative reassessment for hemorrhage control 30 minutes after initial abdominal closure in the operating room focusing on restoration of the patients physiological status specifically reversing hypothermia and coagulopathy
WE CAN HEAR THE HEMORRHAGE
The abdomen is then reopened and assessed for adequacy of hemostasis and for existence of residual mechanical bleeding This practice has allowed surgeons to minimize both early return to the operating room for ongoing hemorrhage and the amount of packing necessary for hemostasis With bleeding effectively controlled the abdomen is reclosed
The patient is transferred to the ICU for continued physiologic restoration in the third phase
Once coagulopathy hypothermia and acidosis have been corrected the patient can be returned to the operating room for definitive management of the injuries in the fourth phase
48-72 h after first surgery
COMPLICATIONS OF DAMAGE CONTROL LAPAROTOMY
1) ACS Acute Compartmental Syndrome
2) ARDS Acute Respiratory Distress of the Adult
3) MOF Multiple organ failure
4) DEATH
ABDOMINAL COMPARTMENT SYNDROME is defined as an intra-abdominal pressure of greater than 20 cm H2O with evidence of impaired organ function ie elevated peak airway pressures (gt45 cm
H2O) oliguria (lt05 mLkg per hour) or cardiovascular dysfunction
(hypotension despite adequate volume resuscitation or if a pulmonary artery catheter is present oxygen delivery index [calculated as milliliters of oxygen per minute per meter squared] of 600) Intra-abdominal pressure was measured indirectly using an indwelling Foley catheter as previously described
Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13 Damage control surgery in the abdomen an approach for the management of severe injured patientsGermanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis NNuffield Department of Surgery John Radcliffe Hospital Oxford UK Curr Opin Crit Care 2006 Aug12(4)346-50 Damage-control laparotomy Lee JC Peitzman AB Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA
ABDOMINAL COMPARTMENT SYNDROME occurred in 17 (33) of
52 Patients undergoing damage-control laparotomy and was
associated with a much higher incidence of ARDS and MOF (71 vs
31 without ACS P = 02)
More importantly our study suggests that primary fascial closure at
the termination of the initial damage-control laparotomy contributes to
the development of ACS as well as subsequent organ failure
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal ypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
Mayberry JC Mullins RJ Crass RA Trunkey DD Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure Arch Surg 1997132957-962
bull MOF Multiple organ failure
Seems to be a major source of postinjury morbidity and the leading cause of in-hospital mortality despite more than 25 years of intense investigation
Eiseman B Beart R Norton L Multiple organ failure Surg Gynecol Obstet 1977144323-326
Bauer AE Durham R Faist E Systemic inflammatory response syndrome (SIRS) multiple organ dysfunction syndrome (MODS) multiple organ failure (MOF) are we winning the battle Shock 19981079-89
The current pathophysiologic model of MOF focuses on uncontrolled systemic
hyperinflammation as a unifying concept following a variety of insults
Moore FA Moore EE Evolving concepts in the pathogenesis of postinjury multiple organ failure Surg Clin North Am 199575257-277
Goris RJ te Boekhorst TP Nuytinck JK Gimbrere JS Multiple-organ failure generalized autodestructive inflammation Arch Surg 19851201109-1115
Nuytinck HK Offermans XJ Kubat K Goris JA Whole-body inflammation in trauma patients an autopsy study Arch Surg 19881231519-1524
Examples that improve the prognosis of MOF include damage control surgery recognition of abdominal compartment syndrome lung protective ventilation
strategies and tight glucose level control
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal hypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
The Acute Respiratory Distress Syndrome Network Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome N Engl J Med 20003421301-1308
Amato MB Barbas CS Medeiros DM et al Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome N Engl J Med 1998338347-354
Van den Berghe G Wouters P Weekers F et al Intensive insulin therapy in the critically ill patients N Engl J Med 20013451359-1367
The incidence of postinjury MOF has been reported to be between 7 and 66 with an associated mortality rate between 31 and 80
Fry DE Pearlstein L Fulton RL Polk HC Jr Multiple system organ failure the role of uncontrolled infection Arch Surg 1980115136-140
Regel G Lobenhoffer P Grotz M Pape HC Lehmann U Tscherne H Treatment results of patients with multiple trauma an analysis of 3406 cases treated between 1972 and 1991 at a German level I trauma center J Trauma 19953870-78
Sauaia A Moore FA Moore EE Norris JM Lezotte DC Hamman RF Multiple organ failure can be predicted as early as 12 hours after injury J Trauma 199845291-303
Nast-Kolb D Aufmkolk M Rucholtz S Obertacke U Waydhas C Multiple organ failure still a major cause of morbidity but not mortality in blunt multiple trauma J Trauma 200151835-842 Durham RM Moran JJ Mazuski JE Shapiro MJ Baue AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
It has been suggested that MOF is disappearing owing to advances in trauma and critical care
Levine JH Durham RM Moran J Bauer A Multiple organ failure is it disappearing World J Surg 199620471-473
Recent reports have not demonstrated a consistent change in either the incidence or the mortality rate associated with postinjury MOF Some groups have reported no change in the incidence but a decreased mortality while others have reported both decreased incidence and mortality compared with historical control subjects
Durham RM Moran JJ Mazuski JE Shapiro MJ Bauer AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
Regel G Grotz M Weltner T Sturm JA Tscherne H Pattern of organ failure following severe trauma World J Surg 199620422-429
Orthopaedic Trauma
Open pelvic fractures in addition to the pelvic ring injury are associated with hemorrhage and neurological insult visceral injuries are more common and a high rate of infection is seen Mortality of open pelvic fractures historically approached 50 Control of bleeding is the most important initial measure followed by debridement and packing of open wounds
Open book- widened symphysis pubis Dislocated Rt SI joint Vallier + Jenkins In Trauma Anesthesia 2008
Type 1 fractures occur due to anterior-posterior
compressioncan cause the symphysis pubis to ldquopoprdquo open leading to pubic rami or ldquoopen
bookrdquo fractures A lateral compression fracture type 2 or vertical sheer facture (Type 3) can
also lead to severe bleeding Into the pelvis Pelvic and acetabular surgery are major surgical interventions
Figura 1- Aplicacioacuten de la engrapadora para la reseccioacuten pulmonar en cuntildea Los segmentos a resecar se limitan por medio de la aplicacioacuten de dispositivos de grapado orientados en direcciones perpendiculares tratando de mantener la mayor cantidad de tejido sano
Insercioacuten de engrapadora lineal cortante a traveacutes de los orificios del tracto de la herida pulmonar penetrante
Figura 3- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales con fuga aeacuterea visible
Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales
Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
- Slide 1
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- Slide 3
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- Slide 5
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-
Current transfusion practices and survival rates of massive transfusion patients vary widely among trauma centers Conventional guidelines may underestimate the optimal plasma and platelet to RBC ratios
Survival in patients is associated with increased plasma and platelet ratios Massive transfusion practice guidelines should aim for a111 ratio of plasma plateletsRBCs bullHolcomb et al Ann Surg 2008248447
Kaplan-Meier survival plot for the first 24 hours after admission for the 4 groups (high plasma (FFPH) or platelet (PltH) to RBC ratio 12 low plasma (FFPL) or platelet (PltL) to RBC ratio 12)
Statistical modeling indicated that a
clinical guideline with mean plasma
RBC ratio equal to 11 would
encompass 98 of patients within
the optimal 12 ratio
Hypotension A systolic blood pressure of 90 mm Hg or less is indicative casualties that have lost over 40 of their blood volume
(~2000 ml in an adult)
They have impending cardiovascular collapse and have significantly increased mortality
The most efficient solution for use in resuscitation is still under debate
Lactated Ringers (LR) and normal isotonic saline solution (NS) remain the
most commonly used isotonic fluids
Although colloid solutions including hyperosmolar colloid and hypertonic
electrolyte compounds have been approved for use as volume expanders
their administration is still under debate in the USA and Europe
Moore FA McKinley BA Moore EE Nathens AB West M Shapiro MB Bankey P Freeman B Harbrecht BG Johnson JL Minei JP Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core standard operating procedures for clinical care III Guidelines for shock resuscitation J Trauma 2006 6182-89 Spahn DR Cerny V Coats TJ Duranteau J Fernandez-Mondejar E Gordini G Stahel PF Hunt BJ Komadina R Neugebauer E Ozier Y Riddez L Schultz A Vincent JL Rossaint R Task Force for Advanced Bleeding Care in Trauma Management of bleeding following major trauma a European guideline Crit Care 2007 11R17
Experimental studies have revealed that resuscitation with NS in the setting of massive hemorrhage requires significantly greater volume and is associated with increased physiologic derangements (for example hyperchloremic acidosis and dilutional coagulopathy) and higher mortality as compared with LR Healey MA Davis RE Liu FC Loomis WH Hoyt DB Lactated ringers is superior to normal saline in a model of massive hemorrhage and resuscitation J Trauma 1998 45894-899 Todd SR Malinoski D Muller PJ Schreiber MA Lactated Ringers is superior to normal saline in the resuscitation of uncontrolled hemorrhagic shock J Trauma 2007 62636-639
Reported data from several studies conducted in critically ill patients have indicated that use of colloid solutions has a significant impact on hemorrhage hemostasis and inflammatory response Roberts I Alderson P Bunn F Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2004 CD000567 Vercueil A Grocott MP Mythen MG Physiology pharmacology and rationale for colloid administration for the maintenance of effective hemodynamic stability in critically ill patients Transfus Med Rev 2005 1993-109 Lee CC Chang IJ Yen ZS Effect of different resuscitation fluids on cytokine response in a rat model of hemorrhagic shock Shock 2005 24177-181
Early administration of blood is one potential treatment to decrease the
need for massive crystalloid solution in hemorrhagic shock however the
limited supply of stored blood and potential adverse effects make this
option logistically difficult and possibly harmful
West MA Sha piro MB Nathens AB Johnson JL Moore EE Minei JP Bankey PE Freeman B Harbrecht BG McKinley BA Moore FA Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core-standard operating procedures for clinical care IV Guidelines for transfusion in the trauma patient J Trauma 2006 61436-439
Moore FA McKinley BA Moore EE Nathens AB West M Shapiro MB Bankey P Freeman B Harbrecht BG Johnson JL Minei JP Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core standard operating procedures for clinical care III Guidelines for shock resuscitation J Trauma 2006 6182-89 Spahn DR Cerny V Coats TJ Duranteau J Fernandez-Mondejar E Gordini G Stahel PF Hunt BJ Komadina R Neugebauer E Ozier Y Riddez L Schultz A Vincent JL Rossaint R Task Force for Advanced Bleeding Care in Trauma Management of bleeding following major trauma a European guideline Crit Care 2007 11R17
Transfusion-related risks include possible development of MOF increased
ICU admissions and length of stay increased hospital length of stay and
mortality
Malone DL Dunne J Tracy JK Putnam AT Scalea TM Napolitano LM Blood transfusion independent of shock severity is associated with worse outcome in trauma J Trauma 2003 54898-905
Eastridge BJ Malone D Holcomb JB Early predictors of transfusion and mortality after injury a review of the data-based literature J Trauma 2006 60S20-S25
Napolitano L Cumulative risks of early red blood cell transfusion J Trauma 2006 60S26-S34
Cotton BA Guy JS Morris JA Jr Abumrad NN The cellular metabolic and systemic consequences of aggressive fluid resuscitation strategies Shock 2006 26115-121
uarr hemorrhage + excessive hemodilution due to
uarr Blood Presion darr blood viscosity darr hematocrit
darr clotting factor concentration
Risks of Aggressive Volume Resuscitation
rFVIIaThe use of rFVIIa was associated with improved early and late survival after severe trauma and massive transfusion
rFVIIa was not associated with increased risk of thrombotic events
The Effect of Recombinant Activated Factor VII on Mortality in Combat-Related Casualties With Severe Trauma and Massive Transfusion
bull Philip C Spinella MD Jeremy G Perkins MD Daniel F McLaughlin MD Sarah E Niles MD MPHKurt W Grathwohl MD Alec C Beekley MD Jose Salinas PhD Sumeru Mehta MD Charles E Wade PhDand John B Holcomb MD J of Trauma- Feb 2008bull Dutton et al J Trauma 200457709 Conclusion consider early use of FVIIa in any pt with uncontrolled hemorrhage who has not responded to surgery or blood component therapy
bull Each unit of blood product biologically active + elevates risk of infections + ARDS (SDRA)Chaiwat et al Anesthesiology 2009110351 n=14070 pts NSCOT database retrospective
bull Older blood association whith elevates infection LOS MOSF + death Weinberg et al J Trauma 200865279
TemperatureA temperature lt 96degF or 35degC is associated with an increase in mortality (cardiac arrest SRP higher abnormal plaquelet function) Burch J Denton J Noble R Physiologic rationale for abbreviated laparotomy Surg Clin North Am 1997 77779-82 Trauma patients that are hypothermic are NOT PERFUSING their tissue
The COAGULATION CASCADE is an enzymatic pathway that degrades with temperature and ceases at 92 FGregory JS Francbeum L Towsened MC Incidence and timing of hypothermia in trauma patients undergoing operations J Trauma 1991 31795-800 If the temperature is lower than 33 C the mortality is 100although Beilman and col think itacutes a significant factor for MODS but not for the mortalityBeilman GJ Blondet JJ Early hypothermia in severely injured trauma patients is a significant risk factor for multiple organ dysfunction syndrome but not mortality Ann Surg 2009 May249(5)845-50
Diagnosis done
Damage Control Resuscitation
1 Hypotensive resuscitation
2 Hemostatic resuscitation
Damage control philosophy can be extended to haemostatic resuscitation
Restoring normal coagulation Minimizing crystalloidTraditional resuscitation strategies dilute the already deficient coagulation factors and increase multiple organ failure
The aggressive hemostatic resuscitation should be combined with equally aggressive control of bleeding
Spahn DR Cerny V Management of bleeding following major trauma a European guidelineCrit Care 2007 11(1) R 17
WAIT AND SEE
SURGEON
ABDOMINAL PACKING is a lifesaving technique for temporary control of severe injury and it is used in damage control surgery schedule
Its possible too applying packs in organ-specific techniques (early abdominal packing)
The median survival of the 70 certainly superior to the obtainable survival with immediate surgical repairbullIMMEDIATE FAILURES are substantially due to bleeding especially in underpacking caseREMOTE FAILURES septic and bound at the time of stay (above the 72 hours) and associated by the coexistence of lesions in these situations is possible a MOF syndrome due to excessive intra-abdominal pressure (overpacking) or to an Abdominal Compartment Syndrome
Stagnitti F Bresadola L Calderale SM Coletti M Ribaldi S Salvi PF Schillaci F Abdominal packing indications and method Ann Ital Chir 2003 Sep-Oct74(5)535-42
Benavides C Garciacutea C Apablaza S Rubilar P Ricaurte F Perales C et al Empaquetamiento hepaacutetico permanente con malla de poliglactina en estallido hepaacutetico secundario a Siacutendrome de Hellp Rev Chil Cir 2004 56 275-278 De la Fuente M Mendoza VH Robledo-Oyarzun F Cierre Temporal de la pared abdominal con polietileno Cir Ciruj 2002 70157-63 Serna VH El Siacutendrome Compartamental Abdominal Tesis de Postgrado Meacutexico 2000
When skin approximation is
not possible a temporary silo
is constructed by suturing a 3-
L cystoscopy irrigation bag
(BOGOTAacute BAG) to the skin
edge with a continuous No 2
nylon suture
The method of closure depends on whether skin approximation produces excessive intra-abdominal hypertension
Towel-clip closure of the skin is preferred because it is quick and easy
The second phase is intra-operative reassessment for hemorrhage control 30 minutes after initial abdominal closure in the operating room focusing on restoration of the patients physiological status specifically reversing hypothermia and coagulopathy
WE CAN HEAR THE HEMORRHAGE
The abdomen is then reopened and assessed for adequacy of hemostasis and for existence of residual mechanical bleeding This practice has allowed surgeons to minimize both early return to the operating room for ongoing hemorrhage and the amount of packing necessary for hemostasis With bleeding effectively controlled the abdomen is reclosed
The patient is transferred to the ICU for continued physiologic restoration in the third phase
Once coagulopathy hypothermia and acidosis have been corrected the patient can be returned to the operating room for definitive management of the injuries in the fourth phase
48-72 h after first surgery
COMPLICATIONS OF DAMAGE CONTROL LAPAROTOMY
1) ACS Acute Compartmental Syndrome
2) ARDS Acute Respiratory Distress of the Adult
3) MOF Multiple organ failure
4) DEATH
ABDOMINAL COMPARTMENT SYNDROME is defined as an intra-abdominal pressure of greater than 20 cm H2O with evidence of impaired organ function ie elevated peak airway pressures (gt45 cm
H2O) oliguria (lt05 mLkg per hour) or cardiovascular dysfunction
(hypotension despite adequate volume resuscitation or if a pulmonary artery catheter is present oxygen delivery index [calculated as milliliters of oxygen per minute per meter squared] of 600) Intra-abdominal pressure was measured indirectly using an indwelling Foley catheter as previously described
Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13 Damage control surgery in the abdomen an approach for the management of severe injured patientsGermanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis NNuffield Department of Surgery John Radcliffe Hospital Oxford UK Curr Opin Crit Care 2006 Aug12(4)346-50 Damage-control laparotomy Lee JC Peitzman AB Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA
ABDOMINAL COMPARTMENT SYNDROME occurred in 17 (33) of
52 Patients undergoing damage-control laparotomy and was
associated with a much higher incidence of ARDS and MOF (71 vs
31 without ACS P = 02)
More importantly our study suggests that primary fascial closure at
the termination of the initial damage-control laparotomy contributes to
the development of ACS as well as subsequent organ failure
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal ypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
Mayberry JC Mullins RJ Crass RA Trunkey DD Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure Arch Surg 1997132957-962
bull MOF Multiple organ failure
Seems to be a major source of postinjury morbidity and the leading cause of in-hospital mortality despite more than 25 years of intense investigation
Eiseman B Beart R Norton L Multiple organ failure Surg Gynecol Obstet 1977144323-326
Bauer AE Durham R Faist E Systemic inflammatory response syndrome (SIRS) multiple organ dysfunction syndrome (MODS) multiple organ failure (MOF) are we winning the battle Shock 19981079-89
The current pathophysiologic model of MOF focuses on uncontrolled systemic
hyperinflammation as a unifying concept following a variety of insults
Moore FA Moore EE Evolving concepts in the pathogenesis of postinjury multiple organ failure Surg Clin North Am 199575257-277
Goris RJ te Boekhorst TP Nuytinck JK Gimbrere JS Multiple-organ failure generalized autodestructive inflammation Arch Surg 19851201109-1115
Nuytinck HK Offermans XJ Kubat K Goris JA Whole-body inflammation in trauma patients an autopsy study Arch Surg 19881231519-1524
Examples that improve the prognosis of MOF include damage control surgery recognition of abdominal compartment syndrome lung protective ventilation
strategies and tight glucose level control
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal hypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
The Acute Respiratory Distress Syndrome Network Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome N Engl J Med 20003421301-1308
Amato MB Barbas CS Medeiros DM et al Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome N Engl J Med 1998338347-354
Van den Berghe G Wouters P Weekers F et al Intensive insulin therapy in the critically ill patients N Engl J Med 20013451359-1367
The incidence of postinjury MOF has been reported to be between 7 and 66 with an associated mortality rate between 31 and 80
Fry DE Pearlstein L Fulton RL Polk HC Jr Multiple system organ failure the role of uncontrolled infection Arch Surg 1980115136-140
Regel G Lobenhoffer P Grotz M Pape HC Lehmann U Tscherne H Treatment results of patients with multiple trauma an analysis of 3406 cases treated between 1972 and 1991 at a German level I trauma center J Trauma 19953870-78
Sauaia A Moore FA Moore EE Norris JM Lezotte DC Hamman RF Multiple organ failure can be predicted as early as 12 hours after injury J Trauma 199845291-303
Nast-Kolb D Aufmkolk M Rucholtz S Obertacke U Waydhas C Multiple organ failure still a major cause of morbidity but not mortality in blunt multiple trauma J Trauma 200151835-842 Durham RM Moran JJ Mazuski JE Shapiro MJ Baue AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
It has been suggested that MOF is disappearing owing to advances in trauma and critical care
Levine JH Durham RM Moran J Bauer A Multiple organ failure is it disappearing World J Surg 199620471-473
Recent reports have not demonstrated a consistent change in either the incidence or the mortality rate associated with postinjury MOF Some groups have reported no change in the incidence but a decreased mortality while others have reported both decreased incidence and mortality compared with historical control subjects
Durham RM Moran JJ Mazuski JE Shapiro MJ Bauer AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
Regel G Grotz M Weltner T Sturm JA Tscherne H Pattern of organ failure following severe trauma World J Surg 199620422-429
Orthopaedic Trauma
Open pelvic fractures in addition to the pelvic ring injury are associated with hemorrhage and neurological insult visceral injuries are more common and a high rate of infection is seen Mortality of open pelvic fractures historically approached 50 Control of bleeding is the most important initial measure followed by debridement and packing of open wounds
Open book- widened symphysis pubis Dislocated Rt SI joint Vallier + Jenkins In Trauma Anesthesia 2008
Type 1 fractures occur due to anterior-posterior
compressioncan cause the symphysis pubis to ldquopoprdquo open leading to pubic rami or ldquoopen
bookrdquo fractures A lateral compression fracture type 2 or vertical sheer facture (Type 3) can
also lead to severe bleeding Into the pelvis Pelvic and acetabular surgery are major surgical interventions
Figura 1- Aplicacioacuten de la engrapadora para la reseccioacuten pulmonar en cuntildea Los segmentos a resecar se limitan por medio de la aplicacioacuten de dispositivos de grapado orientados en direcciones perpendiculares tratando de mantener la mayor cantidad de tejido sano
Insercioacuten de engrapadora lineal cortante a traveacutes de los orificios del tracto de la herida pulmonar penetrante
Figura 3- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales con fuga aeacuterea visible
Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales
Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
- Slide 1
- Slide 2
- Slide 3
- Slide 4
- Slide 5
- Slide 6
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-
Kaplan-Meier survival plot for the first 24 hours after admission for the 4 groups (high plasma (FFPH) or platelet (PltH) to RBC ratio 12 low plasma (FFPL) or platelet (PltL) to RBC ratio 12)
Statistical modeling indicated that a
clinical guideline with mean plasma
RBC ratio equal to 11 would
encompass 98 of patients within
the optimal 12 ratio
Hypotension A systolic blood pressure of 90 mm Hg or less is indicative casualties that have lost over 40 of their blood volume
(~2000 ml in an adult)
They have impending cardiovascular collapse and have significantly increased mortality
The most efficient solution for use in resuscitation is still under debate
Lactated Ringers (LR) and normal isotonic saline solution (NS) remain the
most commonly used isotonic fluids
Although colloid solutions including hyperosmolar colloid and hypertonic
electrolyte compounds have been approved for use as volume expanders
their administration is still under debate in the USA and Europe
Moore FA McKinley BA Moore EE Nathens AB West M Shapiro MB Bankey P Freeman B Harbrecht BG Johnson JL Minei JP Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core standard operating procedures for clinical care III Guidelines for shock resuscitation J Trauma 2006 6182-89 Spahn DR Cerny V Coats TJ Duranteau J Fernandez-Mondejar E Gordini G Stahel PF Hunt BJ Komadina R Neugebauer E Ozier Y Riddez L Schultz A Vincent JL Rossaint R Task Force for Advanced Bleeding Care in Trauma Management of bleeding following major trauma a European guideline Crit Care 2007 11R17
Experimental studies have revealed that resuscitation with NS in the setting of massive hemorrhage requires significantly greater volume and is associated with increased physiologic derangements (for example hyperchloremic acidosis and dilutional coagulopathy) and higher mortality as compared with LR Healey MA Davis RE Liu FC Loomis WH Hoyt DB Lactated ringers is superior to normal saline in a model of massive hemorrhage and resuscitation J Trauma 1998 45894-899 Todd SR Malinoski D Muller PJ Schreiber MA Lactated Ringers is superior to normal saline in the resuscitation of uncontrolled hemorrhagic shock J Trauma 2007 62636-639
Reported data from several studies conducted in critically ill patients have indicated that use of colloid solutions has a significant impact on hemorrhage hemostasis and inflammatory response Roberts I Alderson P Bunn F Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2004 CD000567 Vercueil A Grocott MP Mythen MG Physiology pharmacology and rationale for colloid administration for the maintenance of effective hemodynamic stability in critically ill patients Transfus Med Rev 2005 1993-109 Lee CC Chang IJ Yen ZS Effect of different resuscitation fluids on cytokine response in a rat model of hemorrhagic shock Shock 2005 24177-181
Early administration of blood is one potential treatment to decrease the
need for massive crystalloid solution in hemorrhagic shock however the
limited supply of stored blood and potential adverse effects make this
option logistically difficult and possibly harmful
West MA Sha piro MB Nathens AB Johnson JL Moore EE Minei JP Bankey PE Freeman B Harbrecht BG McKinley BA Moore FA Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core-standard operating procedures for clinical care IV Guidelines for transfusion in the trauma patient J Trauma 2006 61436-439
Moore FA McKinley BA Moore EE Nathens AB West M Shapiro MB Bankey P Freeman B Harbrecht BG Johnson JL Minei JP Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core standard operating procedures for clinical care III Guidelines for shock resuscitation J Trauma 2006 6182-89 Spahn DR Cerny V Coats TJ Duranteau J Fernandez-Mondejar E Gordini G Stahel PF Hunt BJ Komadina R Neugebauer E Ozier Y Riddez L Schultz A Vincent JL Rossaint R Task Force for Advanced Bleeding Care in Trauma Management of bleeding following major trauma a European guideline Crit Care 2007 11R17
Transfusion-related risks include possible development of MOF increased
ICU admissions and length of stay increased hospital length of stay and
mortality
Malone DL Dunne J Tracy JK Putnam AT Scalea TM Napolitano LM Blood transfusion independent of shock severity is associated with worse outcome in trauma J Trauma 2003 54898-905
Eastridge BJ Malone D Holcomb JB Early predictors of transfusion and mortality after injury a review of the data-based literature J Trauma 2006 60S20-S25
Napolitano L Cumulative risks of early red blood cell transfusion J Trauma 2006 60S26-S34
Cotton BA Guy JS Morris JA Jr Abumrad NN The cellular metabolic and systemic consequences of aggressive fluid resuscitation strategies Shock 2006 26115-121
uarr hemorrhage + excessive hemodilution due to
uarr Blood Presion darr blood viscosity darr hematocrit
darr clotting factor concentration
Risks of Aggressive Volume Resuscitation
rFVIIaThe use of rFVIIa was associated with improved early and late survival after severe trauma and massive transfusion
rFVIIa was not associated with increased risk of thrombotic events
The Effect of Recombinant Activated Factor VII on Mortality in Combat-Related Casualties With Severe Trauma and Massive Transfusion
bull Philip C Spinella MD Jeremy G Perkins MD Daniel F McLaughlin MD Sarah E Niles MD MPHKurt W Grathwohl MD Alec C Beekley MD Jose Salinas PhD Sumeru Mehta MD Charles E Wade PhDand John B Holcomb MD J of Trauma- Feb 2008bull Dutton et al J Trauma 200457709 Conclusion consider early use of FVIIa in any pt with uncontrolled hemorrhage who has not responded to surgery or blood component therapy
bull Each unit of blood product biologically active + elevates risk of infections + ARDS (SDRA)Chaiwat et al Anesthesiology 2009110351 n=14070 pts NSCOT database retrospective
bull Older blood association whith elevates infection LOS MOSF + death Weinberg et al J Trauma 200865279
TemperatureA temperature lt 96degF or 35degC is associated with an increase in mortality (cardiac arrest SRP higher abnormal plaquelet function) Burch J Denton J Noble R Physiologic rationale for abbreviated laparotomy Surg Clin North Am 1997 77779-82 Trauma patients that are hypothermic are NOT PERFUSING their tissue
The COAGULATION CASCADE is an enzymatic pathway that degrades with temperature and ceases at 92 FGregory JS Francbeum L Towsened MC Incidence and timing of hypothermia in trauma patients undergoing operations J Trauma 1991 31795-800 If the temperature is lower than 33 C the mortality is 100although Beilman and col think itacutes a significant factor for MODS but not for the mortalityBeilman GJ Blondet JJ Early hypothermia in severely injured trauma patients is a significant risk factor for multiple organ dysfunction syndrome but not mortality Ann Surg 2009 May249(5)845-50
Diagnosis done
Damage Control Resuscitation
1 Hypotensive resuscitation
2 Hemostatic resuscitation
Damage control philosophy can be extended to haemostatic resuscitation
Restoring normal coagulation Minimizing crystalloidTraditional resuscitation strategies dilute the already deficient coagulation factors and increase multiple organ failure
The aggressive hemostatic resuscitation should be combined with equally aggressive control of bleeding
Spahn DR Cerny V Management of bleeding following major trauma a European guidelineCrit Care 2007 11(1) R 17
WAIT AND SEE
SURGEON
ABDOMINAL PACKING is a lifesaving technique for temporary control of severe injury and it is used in damage control surgery schedule
Its possible too applying packs in organ-specific techniques (early abdominal packing)
The median survival of the 70 certainly superior to the obtainable survival with immediate surgical repairbullIMMEDIATE FAILURES are substantially due to bleeding especially in underpacking caseREMOTE FAILURES septic and bound at the time of stay (above the 72 hours) and associated by the coexistence of lesions in these situations is possible a MOF syndrome due to excessive intra-abdominal pressure (overpacking) or to an Abdominal Compartment Syndrome
Stagnitti F Bresadola L Calderale SM Coletti M Ribaldi S Salvi PF Schillaci F Abdominal packing indications and method Ann Ital Chir 2003 Sep-Oct74(5)535-42
Benavides C Garciacutea C Apablaza S Rubilar P Ricaurte F Perales C et al Empaquetamiento hepaacutetico permanente con malla de poliglactina en estallido hepaacutetico secundario a Siacutendrome de Hellp Rev Chil Cir 2004 56 275-278 De la Fuente M Mendoza VH Robledo-Oyarzun F Cierre Temporal de la pared abdominal con polietileno Cir Ciruj 2002 70157-63 Serna VH El Siacutendrome Compartamental Abdominal Tesis de Postgrado Meacutexico 2000
When skin approximation is
not possible a temporary silo
is constructed by suturing a 3-
L cystoscopy irrigation bag
(BOGOTAacute BAG) to the skin
edge with a continuous No 2
nylon suture
The method of closure depends on whether skin approximation produces excessive intra-abdominal hypertension
Towel-clip closure of the skin is preferred because it is quick and easy
The second phase is intra-operative reassessment for hemorrhage control 30 minutes after initial abdominal closure in the operating room focusing on restoration of the patients physiological status specifically reversing hypothermia and coagulopathy
WE CAN HEAR THE HEMORRHAGE
The abdomen is then reopened and assessed for adequacy of hemostasis and for existence of residual mechanical bleeding This practice has allowed surgeons to minimize both early return to the operating room for ongoing hemorrhage and the amount of packing necessary for hemostasis With bleeding effectively controlled the abdomen is reclosed
The patient is transferred to the ICU for continued physiologic restoration in the third phase
Once coagulopathy hypothermia and acidosis have been corrected the patient can be returned to the operating room for definitive management of the injuries in the fourth phase
48-72 h after first surgery
COMPLICATIONS OF DAMAGE CONTROL LAPAROTOMY
1) ACS Acute Compartmental Syndrome
2) ARDS Acute Respiratory Distress of the Adult
3) MOF Multiple organ failure
4) DEATH
ABDOMINAL COMPARTMENT SYNDROME is defined as an intra-abdominal pressure of greater than 20 cm H2O with evidence of impaired organ function ie elevated peak airway pressures (gt45 cm
H2O) oliguria (lt05 mLkg per hour) or cardiovascular dysfunction
(hypotension despite adequate volume resuscitation or if a pulmonary artery catheter is present oxygen delivery index [calculated as milliliters of oxygen per minute per meter squared] of 600) Intra-abdominal pressure was measured indirectly using an indwelling Foley catheter as previously described
Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13 Damage control surgery in the abdomen an approach for the management of severe injured patientsGermanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis NNuffield Department of Surgery John Radcliffe Hospital Oxford UK Curr Opin Crit Care 2006 Aug12(4)346-50 Damage-control laparotomy Lee JC Peitzman AB Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA
ABDOMINAL COMPARTMENT SYNDROME occurred in 17 (33) of
52 Patients undergoing damage-control laparotomy and was
associated with a much higher incidence of ARDS and MOF (71 vs
31 without ACS P = 02)
More importantly our study suggests that primary fascial closure at
the termination of the initial damage-control laparotomy contributes to
the development of ACS as well as subsequent organ failure
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal ypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
Mayberry JC Mullins RJ Crass RA Trunkey DD Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure Arch Surg 1997132957-962
bull MOF Multiple organ failure
Seems to be a major source of postinjury morbidity and the leading cause of in-hospital mortality despite more than 25 years of intense investigation
Eiseman B Beart R Norton L Multiple organ failure Surg Gynecol Obstet 1977144323-326
Bauer AE Durham R Faist E Systemic inflammatory response syndrome (SIRS) multiple organ dysfunction syndrome (MODS) multiple organ failure (MOF) are we winning the battle Shock 19981079-89
The current pathophysiologic model of MOF focuses on uncontrolled systemic
hyperinflammation as a unifying concept following a variety of insults
Moore FA Moore EE Evolving concepts in the pathogenesis of postinjury multiple organ failure Surg Clin North Am 199575257-277
Goris RJ te Boekhorst TP Nuytinck JK Gimbrere JS Multiple-organ failure generalized autodestructive inflammation Arch Surg 19851201109-1115
Nuytinck HK Offermans XJ Kubat K Goris JA Whole-body inflammation in trauma patients an autopsy study Arch Surg 19881231519-1524
Examples that improve the prognosis of MOF include damage control surgery recognition of abdominal compartment syndrome lung protective ventilation
strategies and tight glucose level control
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal hypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
The Acute Respiratory Distress Syndrome Network Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome N Engl J Med 20003421301-1308
Amato MB Barbas CS Medeiros DM et al Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome N Engl J Med 1998338347-354
Van den Berghe G Wouters P Weekers F et al Intensive insulin therapy in the critically ill patients N Engl J Med 20013451359-1367
The incidence of postinjury MOF has been reported to be between 7 and 66 with an associated mortality rate between 31 and 80
Fry DE Pearlstein L Fulton RL Polk HC Jr Multiple system organ failure the role of uncontrolled infection Arch Surg 1980115136-140
Regel G Lobenhoffer P Grotz M Pape HC Lehmann U Tscherne H Treatment results of patients with multiple trauma an analysis of 3406 cases treated between 1972 and 1991 at a German level I trauma center J Trauma 19953870-78
Sauaia A Moore FA Moore EE Norris JM Lezotte DC Hamman RF Multiple organ failure can be predicted as early as 12 hours after injury J Trauma 199845291-303
Nast-Kolb D Aufmkolk M Rucholtz S Obertacke U Waydhas C Multiple organ failure still a major cause of morbidity but not mortality in blunt multiple trauma J Trauma 200151835-842 Durham RM Moran JJ Mazuski JE Shapiro MJ Baue AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
It has been suggested that MOF is disappearing owing to advances in trauma and critical care
Levine JH Durham RM Moran J Bauer A Multiple organ failure is it disappearing World J Surg 199620471-473
Recent reports have not demonstrated a consistent change in either the incidence or the mortality rate associated with postinjury MOF Some groups have reported no change in the incidence but a decreased mortality while others have reported both decreased incidence and mortality compared with historical control subjects
Durham RM Moran JJ Mazuski JE Shapiro MJ Bauer AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
Regel G Grotz M Weltner T Sturm JA Tscherne H Pattern of organ failure following severe trauma World J Surg 199620422-429
Orthopaedic Trauma
Open pelvic fractures in addition to the pelvic ring injury are associated with hemorrhage and neurological insult visceral injuries are more common and a high rate of infection is seen Mortality of open pelvic fractures historically approached 50 Control of bleeding is the most important initial measure followed by debridement and packing of open wounds
Open book- widened symphysis pubis Dislocated Rt SI joint Vallier + Jenkins In Trauma Anesthesia 2008
Type 1 fractures occur due to anterior-posterior
compressioncan cause the symphysis pubis to ldquopoprdquo open leading to pubic rami or ldquoopen
bookrdquo fractures A lateral compression fracture type 2 or vertical sheer facture (Type 3) can
also lead to severe bleeding Into the pelvis Pelvic and acetabular surgery are major surgical interventions
Figura 1- Aplicacioacuten de la engrapadora para la reseccioacuten pulmonar en cuntildea Los segmentos a resecar se limitan por medio de la aplicacioacuten de dispositivos de grapado orientados en direcciones perpendiculares tratando de mantener la mayor cantidad de tejido sano
Insercioacuten de engrapadora lineal cortante a traveacutes de los orificios del tracto de la herida pulmonar penetrante
Figura 3- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales con fuga aeacuterea visible
Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales
Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
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- Slide 31
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- Slide 35
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- Slide 37
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- Slide 57
- Slide 58
- Slide 59
-
Hypotension A systolic blood pressure of 90 mm Hg or less is indicative casualties that have lost over 40 of their blood volume
(~2000 ml in an adult)
They have impending cardiovascular collapse and have significantly increased mortality
The most efficient solution for use in resuscitation is still under debate
Lactated Ringers (LR) and normal isotonic saline solution (NS) remain the
most commonly used isotonic fluids
Although colloid solutions including hyperosmolar colloid and hypertonic
electrolyte compounds have been approved for use as volume expanders
their administration is still under debate in the USA and Europe
Moore FA McKinley BA Moore EE Nathens AB West M Shapiro MB Bankey P Freeman B Harbrecht BG Johnson JL Minei JP Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core standard operating procedures for clinical care III Guidelines for shock resuscitation J Trauma 2006 6182-89 Spahn DR Cerny V Coats TJ Duranteau J Fernandez-Mondejar E Gordini G Stahel PF Hunt BJ Komadina R Neugebauer E Ozier Y Riddez L Schultz A Vincent JL Rossaint R Task Force for Advanced Bleeding Care in Trauma Management of bleeding following major trauma a European guideline Crit Care 2007 11R17
Experimental studies have revealed that resuscitation with NS in the setting of massive hemorrhage requires significantly greater volume and is associated with increased physiologic derangements (for example hyperchloremic acidosis and dilutional coagulopathy) and higher mortality as compared with LR Healey MA Davis RE Liu FC Loomis WH Hoyt DB Lactated ringers is superior to normal saline in a model of massive hemorrhage and resuscitation J Trauma 1998 45894-899 Todd SR Malinoski D Muller PJ Schreiber MA Lactated Ringers is superior to normal saline in the resuscitation of uncontrolled hemorrhagic shock J Trauma 2007 62636-639
Reported data from several studies conducted in critically ill patients have indicated that use of colloid solutions has a significant impact on hemorrhage hemostasis and inflammatory response Roberts I Alderson P Bunn F Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2004 CD000567 Vercueil A Grocott MP Mythen MG Physiology pharmacology and rationale for colloid administration for the maintenance of effective hemodynamic stability in critically ill patients Transfus Med Rev 2005 1993-109 Lee CC Chang IJ Yen ZS Effect of different resuscitation fluids on cytokine response in a rat model of hemorrhagic shock Shock 2005 24177-181
Early administration of blood is one potential treatment to decrease the
need for massive crystalloid solution in hemorrhagic shock however the
limited supply of stored blood and potential adverse effects make this
option logistically difficult and possibly harmful
West MA Sha piro MB Nathens AB Johnson JL Moore EE Minei JP Bankey PE Freeman B Harbrecht BG McKinley BA Moore FA Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core-standard operating procedures for clinical care IV Guidelines for transfusion in the trauma patient J Trauma 2006 61436-439
Moore FA McKinley BA Moore EE Nathens AB West M Shapiro MB Bankey P Freeman B Harbrecht BG Johnson JL Minei JP Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core standard operating procedures for clinical care III Guidelines for shock resuscitation J Trauma 2006 6182-89 Spahn DR Cerny V Coats TJ Duranteau J Fernandez-Mondejar E Gordini G Stahel PF Hunt BJ Komadina R Neugebauer E Ozier Y Riddez L Schultz A Vincent JL Rossaint R Task Force for Advanced Bleeding Care in Trauma Management of bleeding following major trauma a European guideline Crit Care 2007 11R17
Transfusion-related risks include possible development of MOF increased
ICU admissions and length of stay increased hospital length of stay and
mortality
Malone DL Dunne J Tracy JK Putnam AT Scalea TM Napolitano LM Blood transfusion independent of shock severity is associated with worse outcome in trauma J Trauma 2003 54898-905
Eastridge BJ Malone D Holcomb JB Early predictors of transfusion and mortality after injury a review of the data-based literature J Trauma 2006 60S20-S25
Napolitano L Cumulative risks of early red blood cell transfusion J Trauma 2006 60S26-S34
Cotton BA Guy JS Morris JA Jr Abumrad NN The cellular metabolic and systemic consequences of aggressive fluid resuscitation strategies Shock 2006 26115-121
uarr hemorrhage + excessive hemodilution due to
uarr Blood Presion darr blood viscosity darr hematocrit
darr clotting factor concentration
Risks of Aggressive Volume Resuscitation
rFVIIaThe use of rFVIIa was associated with improved early and late survival after severe trauma and massive transfusion
rFVIIa was not associated with increased risk of thrombotic events
The Effect of Recombinant Activated Factor VII on Mortality in Combat-Related Casualties With Severe Trauma and Massive Transfusion
bull Philip C Spinella MD Jeremy G Perkins MD Daniel F McLaughlin MD Sarah E Niles MD MPHKurt W Grathwohl MD Alec C Beekley MD Jose Salinas PhD Sumeru Mehta MD Charles E Wade PhDand John B Holcomb MD J of Trauma- Feb 2008bull Dutton et al J Trauma 200457709 Conclusion consider early use of FVIIa in any pt with uncontrolled hemorrhage who has not responded to surgery or blood component therapy
bull Each unit of blood product biologically active + elevates risk of infections + ARDS (SDRA)Chaiwat et al Anesthesiology 2009110351 n=14070 pts NSCOT database retrospective
bull Older blood association whith elevates infection LOS MOSF + death Weinberg et al J Trauma 200865279
TemperatureA temperature lt 96degF or 35degC is associated with an increase in mortality (cardiac arrest SRP higher abnormal plaquelet function) Burch J Denton J Noble R Physiologic rationale for abbreviated laparotomy Surg Clin North Am 1997 77779-82 Trauma patients that are hypothermic are NOT PERFUSING their tissue
The COAGULATION CASCADE is an enzymatic pathway that degrades with temperature and ceases at 92 FGregory JS Francbeum L Towsened MC Incidence and timing of hypothermia in trauma patients undergoing operations J Trauma 1991 31795-800 If the temperature is lower than 33 C the mortality is 100although Beilman and col think itacutes a significant factor for MODS but not for the mortalityBeilman GJ Blondet JJ Early hypothermia in severely injured trauma patients is a significant risk factor for multiple organ dysfunction syndrome but not mortality Ann Surg 2009 May249(5)845-50
Diagnosis done
Damage Control Resuscitation
1 Hypotensive resuscitation
2 Hemostatic resuscitation
Damage control philosophy can be extended to haemostatic resuscitation
Restoring normal coagulation Minimizing crystalloidTraditional resuscitation strategies dilute the already deficient coagulation factors and increase multiple organ failure
The aggressive hemostatic resuscitation should be combined with equally aggressive control of bleeding
Spahn DR Cerny V Management of bleeding following major trauma a European guidelineCrit Care 2007 11(1) R 17
WAIT AND SEE
SURGEON
ABDOMINAL PACKING is a lifesaving technique for temporary control of severe injury and it is used in damage control surgery schedule
Its possible too applying packs in organ-specific techniques (early abdominal packing)
The median survival of the 70 certainly superior to the obtainable survival with immediate surgical repairbullIMMEDIATE FAILURES are substantially due to bleeding especially in underpacking caseREMOTE FAILURES septic and bound at the time of stay (above the 72 hours) and associated by the coexistence of lesions in these situations is possible a MOF syndrome due to excessive intra-abdominal pressure (overpacking) or to an Abdominal Compartment Syndrome
Stagnitti F Bresadola L Calderale SM Coletti M Ribaldi S Salvi PF Schillaci F Abdominal packing indications and method Ann Ital Chir 2003 Sep-Oct74(5)535-42
Benavides C Garciacutea C Apablaza S Rubilar P Ricaurte F Perales C et al Empaquetamiento hepaacutetico permanente con malla de poliglactina en estallido hepaacutetico secundario a Siacutendrome de Hellp Rev Chil Cir 2004 56 275-278 De la Fuente M Mendoza VH Robledo-Oyarzun F Cierre Temporal de la pared abdominal con polietileno Cir Ciruj 2002 70157-63 Serna VH El Siacutendrome Compartamental Abdominal Tesis de Postgrado Meacutexico 2000
When skin approximation is
not possible a temporary silo
is constructed by suturing a 3-
L cystoscopy irrigation bag
(BOGOTAacute BAG) to the skin
edge with a continuous No 2
nylon suture
The method of closure depends on whether skin approximation produces excessive intra-abdominal hypertension
Towel-clip closure of the skin is preferred because it is quick and easy
The second phase is intra-operative reassessment for hemorrhage control 30 minutes after initial abdominal closure in the operating room focusing on restoration of the patients physiological status specifically reversing hypothermia and coagulopathy
WE CAN HEAR THE HEMORRHAGE
The abdomen is then reopened and assessed for adequacy of hemostasis and for existence of residual mechanical bleeding This practice has allowed surgeons to minimize both early return to the operating room for ongoing hemorrhage and the amount of packing necessary for hemostasis With bleeding effectively controlled the abdomen is reclosed
The patient is transferred to the ICU for continued physiologic restoration in the third phase
Once coagulopathy hypothermia and acidosis have been corrected the patient can be returned to the operating room for definitive management of the injuries in the fourth phase
48-72 h after first surgery
COMPLICATIONS OF DAMAGE CONTROL LAPAROTOMY
1) ACS Acute Compartmental Syndrome
2) ARDS Acute Respiratory Distress of the Adult
3) MOF Multiple organ failure
4) DEATH
ABDOMINAL COMPARTMENT SYNDROME is defined as an intra-abdominal pressure of greater than 20 cm H2O with evidence of impaired organ function ie elevated peak airway pressures (gt45 cm
H2O) oliguria (lt05 mLkg per hour) or cardiovascular dysfunction
(hypotension despite adequate volume resuscitation or if a pulmonary artery catheter is present oxygen delivery index [calculated as milliliters of oxygen per minute per meter squared] of 600) Intra-abdominal pressure was measured indirectly using an indwelling Foley catheter as previously described
Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13 Damage control surgery in the abdomen an approach for the management of severe injured patientsGermanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis NNuffield Department of Surgery John Radcliffe Hospital Oxford UK Curr Opin Crit Care 2006 Aug12(4)346-50 Damage-control laparotomy Lee JC Peitzman AB Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA
ABDOMINAL COMPARTMENT SYNDROME occurred in 17 (33) of
52 Patients undergoing damage-control laparotomy and was
associated with a much higher incidence of ARDS and MOF (71 vs
31 without ACS P = 02)
More importantly our study suggests that primary fascial closure at
the termination of the initial damage-control laparotomy contributes to
the development of ACS as well as subsequent organ failure
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal ypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
Mayberry JC Mullins RJ Crass RA Trunkey DD Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure Arch Surg 1997132957-962
bull MOF Multiple organ failure
Seems to be a major source of postinjury morbidity and the leading cause of in-hospital mortality despite more than 25 years of intense investigation
Eiseman B Beart R Norton L Multiple organ failure Surg Gynecol Obstet 1977144323-326
Bauer AE Durham R Faist E Systemic inflammatory response syndrome (SIRS) multiple organ dysfunction syndrome (MODS) multiple organ failure (MOF) are we winning the battle Shock 19981079-89
The current pathophysiologic model of MOF focuses on uncontrolled systemic
hyperinflammation as a unifying concept following a variety of insults
Moore FA Moore EE Evolving concepts in the pathogenesis of postinjury multiple organ failure Surg Clin North Am 199575257-277
Goris RJ te Boekhorst TP Nuytinck JK Gimbrere JS Multiple-organ failure generalized autodestructive inflammation Arch Surg 19851201109-1115
Nuytinck HK Offermans XJ Kubat K Goris JA Whole-body inflammation in trauma patients an autopsy study Arch Surg 19881231519-1524
Examples that improve the prognosis of MOF include damage control surgery recognition of abdominal compartment syndrome lung protective ventilation
strategies and tight glucose level control
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal hypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
The Acute Respiratory Distress Syndrome Network Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome N Engl J Med 20003421301-1308
Amato MB Barbas CS Medeiros DM et al Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome N Engl J Med 1998338347-354
Van den Berghe G Wouters P Weekers F et al Intensive insulin therapy in the critically ill patients N Engl J Med 20013451359-1367
The incidence of postinjury MOF has been reported to be between 7 and 66 with an associated mortality rate between 31 and 80
Fry DE Pearlstein L Fulton RL Polk HC Jr Multiple system organ failure the role of uncontrolled infection Arch Surg 1980115136-140
Regel G Lobenhoffer P Grotz M Pape HC Lehmann U Tscherne H Treatment results of patients with multiple trauma an analysis of 3406 cases treated between 1972 and 1991 at a German level I trauma center J Trauma 19953870-78
Sauaia A Moore FA Moore EE Norris JM Lezotte DC Hamman RF Multiple organ failure can be predicted as early as 12 hours after injury J Trauma 199845291-303
Nast-Kolb D Aufmkolk M Rucholtz S Obertacke U Waydhas C Multiple organ failure still a major cause of morbidity but not mortality in blunt multiple trauma J Trauma 200151835-842 Durham RM Moran JJ Mazuski JE Shapiro MJ Baue AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
It has been suggested that MOF is disappearing owing to advances in trauma and critical care
Levine JH Durham RM Moran J Bauer A Multiple organ failure is it disappearing World J Surg 199620471-473
Recent reports have not demonstrated a consistent change in either the incidence or the mortality rate associated with postinjury MOF Some groups have reported no change in the incidence but a decreased mortality while others have reported both decreased incidence and mortality compared with historical control subjects
Durham RM Moran JJ Mazuski JE Shapiro MJ Bauer AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
Regel G Grotz M Weltner T Sturm JA Tscherne H Pattern of organ failure following severe trauma World J Surg 199620422-429
Orthopaedic Trauma
Open pelvic fractures in addition to the pelvic ring injury are associated with hemorrhage and neurological insult visceral injuries are more common and a high rate of infection is seen Mortality of open pelvic fractures historically approached 50 Control of bleeding is the most important initial measure followed by debridement and packing of open wounds
Open book- widened symphysis pubis Dislocated Rt SI joint Vallier + Jenkins In Trauma Anesthesia 2008
Type 1 fractures occur due to anterior-posterior
compressioncan cause the symphysis pubis to ldquopoprdquo open leading to pubic rami or ldquoopen
bookrdquo fractures A lateral compression fracture type 2 or vertical sheer facture (Type 3) can
also lead to severe bleeding Into the pelvis Pelvic and acetabular surgery are major surgical interventions
Figura 1- Aplicacioacuten de la engrapadora para la reseccioacuten pulmonar en cuntildea Los segmentos a resecar se limitan por medio de la aplicacioacuten de dispositivos de grapado orientados en direcciones perpendiculares tratando de mantener la mayor cantidad de tejido sano
Insercioacuten de engrapadora lineal cortante a traveacutes de los orificios del tracto de la herida pulmonar penetrante
Figura 3- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales con fuga aeacuterea visible
Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales
Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
- Slide 1
- Slide 2
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
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- Slide 31
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- Slide 35
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- Slide 37
- Slide 38
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-
The most efficient solution for use in resuscitation is still under debate
Lactated Ringers (LR) and normal isotonic saline solution (NS) remain the
most commonly used isotonic fluids
Although colloid solutions including hyperosmolar colloid and hypertonic
electrolyte compounds have been approved for use as volume expanders
their administration is still under debate in the USA and Europe
Moore FA McKinley BA Moore EE Nathens AB West M Shapiro MB Bankey P Freeman B Harbrecht BG Johnson JL Minei JP Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core standard operating procedures for clinical care III Guidelines for shock resuscitation J Trauma 2006 6182-89 Spahn DR Cerny V Coats TJ Duranteau J Fernandez-Mondejar E Gordini G Stahel PF Hunt BJ Komadina R Neugebauer E Ozier Y Riddez L Schultz A Vincent JL Rossaint R Task Force for Advanced Bleeding Care in Trauma Management of bleeding following major trauma a European guideline Crit Care 2007 11R17
Experimental studies have revealed that resuscitation with NS in the setting of massive hemorrhage requires significantly greater volume and is associated with increased physiologic derangements (for example hyperchloremic acidosis and dilutional coagulopathy) and higher mortality as compared with LR Healey MA Davis RE Liu FC Loomis WH Hoyt DB Lactated ringers is superior to normal saline in a model of massive hemorrhage and resuscitation J Trauma 1998 45894-899 Todd SR Malinoski D Muller PJ Schreiber MA Lactated Ringers is superior to normal saline in the resuscitation of uncontrolled hemorrhagic shock J Trauma 2007 62636-639
Reported data from several studies conducted in critically ill patients have indicated that use of colloid solutions has a significant impact on hemorrhage hemostasis and inflammatory response Roberts I Alderson P Bunn F Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2004 CD000567 Vercueil A Grocott MP Mythen MG Physiology pharmacology and rationale for colloid administration for the maintenance of effective hemodynamic stability in critically ill patients Transfus Med Rev 2005 1993-109 Lee CC Chang IJ Yen ZS Effect of different resuscitation fluids on cytokine response in a rat model of hemorrhagic shock Shock 2005 24177-181
Early administration of blood is one potential treatment to decrease the
need for massive crystalloid solution in hemorrhagic shock however the
limited supply of stored blood and potential adverse effects make this
option logistically difficult and possibly harmful
West MA Sha piro MB Nathens AB Johnson JL Moore EE Minei JP Bankey PE Freeman B Harbrecht BG McKinley BA Moore FA Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core-standard operating procedures for clinical care IV Guidelines for transfusion in the trauma patient J Trauma 2006 61436-439
Moore FA McKinley BA Moore EE Nathens AB West M Shapiro MB Bankey P Freeman B Harbrecht BG Johnson JL Minei JP Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core standard operating procedures for clinical care III Guidelines for shock resuscitation J Trauma 2006 6182-89 Spahn DR Cerny V Coats TJ Duranteau J Fernandez-Mondejar E Gordini G Stahel PF Hunt BJ Komadina R Neugebauer E Ozier Y Riddez L Schultz A Vincent JL Rossaint R Task Force for Advanced Bleeding Care in Trauma Management of bleeding following major trauma a European guideline Crit Care 2007 11R17
Transfusion-related risks include possible development of MOF increased
ICU admissions and length of stay increased hospital length of stay and
mortality
Malone DL Dunne J Tracy JK Putnam AT Scalea TM Napolitano LM Blood transfusion independent of shock severity is associated with worse outcome in trauma J Trauma 2003 54898-905
Eastridge BJ Malone D Holcomb JB Early predictors of transfusion and mortality after injury a review of the data-based literature J Trauma 2006 60S20-S25
Napolitano L Cumulative risks of early red blood cell transfusion J Trauma 2006 60S26-S34
Cotton BA Guy JS Morris JA Jr Abumrad NN The cellular metabolic and systemic consequences of aggressive fluid resuscitation strategies Shock 2006 26115-121
uarr hemorrhage + excessive hemodilution due to
uarr Blood Presion darr blood viscosity darr hematocrit
darr clotting factor concentration
Risks of Aggressive Volume Resuscitation
rFVIIaThe use of rFVIIa was associated with improved early and late survival after severe trauma and massive transfusion
rFVIIa was not associated with increased risk of thrombotic events
The Effect of Recombinant Activated Factor VII on Mortality in Combat-Related Casualties With Severe Trauma and Massive Transfusion
bull Philip C Spinella MD Jeremy G Perkins MD Daniel F McLaughlin MD Sarah E Niles MD MPHKurt W Grathwohl MD Alec C Beekley MD Jose Salinas PhD Sumeru Mehta MD Charles E Wade PhDand John B Holcomb MD J of Trauma- Feb 2008bull Dutton et al J Trauma 200457709 Conclusion consider early use of FVIIa in any pt with uncontrolled hemorrhage who has not responded to surgery or blood component therapy
bull Each unit of blood product biologically active + elevates risk of infections + ARDS (SDRA)Chaiwat et al Anesthesiology 2009110351 n=14070 pts NSCOT database retrospective
bull Older blood association whith elevates infection LOS MOSF + death Weinberg et al J Trauma 200865279
TemperatureA temperature lt 96degF or 35degC is associated with an increase in mortality (cardiac arrest SRP higher abnormal plaquelet function) Burch J Denton J Noble R Physiologic rationale for abbreviated laparotomy Surg Clin North Am 1997 77779-82 Trauma patients that are hypothermic are NOT PERFUSING their tissue
The COAGULATION CASCADE is an enzymatic pathway that degrades with temperature and ceases at 92 FGregory JS Francbeum L Towsened MC Incidence and timing of hypothermia in trauma patients undergoing operations J Trauma 1991 31795-800 If the temperature is lower than 33 C the mortality is 100although Beilman and col think itacutes a significant factor for MODS but not for the mortalityBeilman GJ Blondet JJ Early hypothermia in severely injured trauma patients is a significant risk factor for multiple organ dysfunction syndrome but not mortality Ann Surg 2009 May249(5)845-50
Diagnosis done
Damage Control Resuscitation
1 Hypotensive resuscitation
2 Hemostatic resuscitation
Damage control philosophy can be extended to haemostatic resuscitation
Restoring normal coagulation Minimizing crystalloidTraditional resuscitation strategies dilute the already deficient coagulation factors and increase multiple organ failure
The aggressive hemostatic resuscitation should be combined with equally aggressive control of bleeding
Spahn DR Cerny V Management of bleeding following major trauma a European guidelineCrit Care 2007 11(1) R 17
WAIT AND SEE
SURGEON
ABDOMINAL PACKING is a lifesaving technique for temporary control of severe injury and it is used in damage control surgery schedule
Its possible too applying packs in organ-specific techniques (early abdominal packing)
The median survival of the 70 certainly superior to the obtainable survival with immediate surgical repairbullIMMEDIATE FAILURES are substantially due to bleeding especially in underpacking caseREMOTE FAILURES septic and bound at the time of stay (above the 72 hours) and associated by the coexistence of lesions in these situations is possible a MOF syndrome due to excessive intra-abdominal pressure (overpacking) or to an Abdominal Compartment Syndrome
Stagnitti F Bresadola L Calderale SM Coletti M Ribaldi S Salvi PF Schillaci F Abdominal packing indications and method Ann Ital Chir 2003 Sep-Oct74(5)535-42
Benavides C Garciacutea C Apablaza S Rubilar P Ricaurte F Perales C et al Empaquetamiento hepaacutetico permanente con malla de poliglactina en estallido hepaacutetico secundario a Siacutendrome de Hellp Rev Chil Cir 2004 56 275-278 De la Fuente M Mendoza VH Robledo-Oyarzun F Cierre Temporal de la pared abdominal con polietileno Cir Ciruj 2002 70157-63 Serna VH El Siacutendrome Compartamental Abdominal Tesis de Postgrado Meacutexico 2000
When skin approximation is
not possible a temporary silo
is constructed by suturing a 3-
L cystoscopy irrigation bag
(BOGOTAacute BAG) to the skin
edge with a continuous No 2
nylon suture
The method of closure depends on whether skin approximation produces excessive intra-abdominal hypertension
Towel-clip closure of the skin is preferred because it is quick and easy
The second phase is intra-operative reassessment for hemorrhage control 30 minutes after initial abdominal closure in the operating room focusing on restoration of the patients physiological status specifically reversing hypothermia and coagulopathy
WE CAN HEAR THE HEMORRHAGE
The abdomen is then reopened and assessed for adequacy of hemostasis and for existence of residual mechanical bleeding This practice has allowed surgeons to minimize both early return to the operating room for ongoing hemorrhage and the amount of packing necessary for hemostasis With bleeding effectively controlled the abdomen is reclosed
The patient is transferred to the ICU for continued physiologic restoration in the third phase
Once coagulopathy hypothermia and acidosis have been corrected the patient can be returned to the operating room for definitive management of the injuries in the fourth phase
48-72 h after first surgery
COMPLICATIONS OF DAMAGE CONTROL LAPAROTOMY
1) ACS Acute Compartmental Syndrome
2) ARDS Acute Respiratory Distress of the Adult
3) MOF Multiple organ failure
4) DEATH
ABDOMINAL COMPARTMENT SYNDROME is defined as an intra-abdominal pressure of greater than 20 cm H2O with evidence of impaired organ function ie elevated peak airway pressures (gt45 cm
H2O) oliguria (lt05 mLkg per hour) or cardiovascular dysfunction
(hypotension despite adequate volume resuscitation or if a pulmonary artery catheter is present oxygen delivery index [calculated as milliliters of oxygen per minute per meter squared] of 600) Intra-abdominal pressure was measured indirectly using an indwelling Foley catheter as previously described
Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13 Damage control surgery in the abdomen an approach for the management of severe injured patientsGermanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis NNuffield Department of Surgery John Radcliffe Hospital Oxford UK Curr Opin Crit Care 2006 Aug12(4)346-50 Damage-control laparotomy Lee JC Peitzman AB Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA
ABDOMINAL COMPARTMENT SYNDROME occurred in 17 (33) of
52 Patients undergoing damage-control laparotomy and was
associated with a much higher incidence of ARDS and MOF (71 vs
31 without ACS P = 02)
More importantly our study suggests that primary fascial closure at
the termination of the initial damage-control laparotomy contributes to
the development of ACS as well as subsequent organ failure
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal ypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
Mayberry JC Mullins RJ Crass RA Trunkey DD Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure Arch Surg 1997132957-962
bull MOF Multiple organ failure
Seems to be a major source of postinjury morbidity and the leading cause of in-hospital mortality despite more than 25 years of intense investigation
Eiseman B Beart R Norton L Multiple organ failure Surg Gynecol Obstet 1977144323-326
Bauer AE Durham R Faist E Systemic inflammatory response syndrome (SIRS) multiple organ dysfunction syndrome (MODS) multiple organ failure (MOF) are we winning the battle Shock 19981079-89
The current pathophysiologic model of MOF focuses on uncontrolled systemic
hyperinflammation as a unifying concept following a variety of insults
Moore FA Moore EE Evolving concepts in the pathogenesis of postinjury multiple organ failure Surg Clin North Am 199575257-277
Goris RJ te Boekhorst TP Nuytinck JK Gimbrere JS Multiple-organ failure generalized autodestructive inflammation Arch Surg 19851201109-1115
Nuytinck HK Offermans XJ Kubat K Goris JA Whole-body inflammation in trauma patients an autopsy study Arch Surg 19881231519-1524
Examples that improve the prognosis of MOF include damage control surgery recognition of abdominal compartment syndrome lung protective ventilation
strategies and tight glucose level control
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal hypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
The Acute Respiratory Distress Syndrome Network Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome N Engl J Med 20003421301-1308
Amato MB Barbas CS Medeiros DM et al Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome N Engl J Med 1998338347-354
Van den Berghe G Wouters P Weekers F et al Intensive insulin therapy in the critically ill patients N Engl J Med 20013451359-1367
The incidence of postinjury MOF has been reported to be between 7 and 66 with an associated mortality rate between 31 and 80
Fry DE Pearlstein L Fulton RL Polk HC Jr Multiple system organ failure the role of uncontrolled infection Arch Surg 1980115136-140
Regel G Lobenhoffer P Grotz M Pape HC Lehmann U Tscherne H Treatment results of patients with multiple trauma an analysis of 3406 cases treated between 1972 and 1991 at a German level I trauma center J Trauma 19953870-78
Sauaia A Moore FA Moore EE Norris JM Lezotte DC Hamman RF Multiple organ failure can be predicted as early as 12 hours after injury J Trauma 199845291-303
Nast-Kolb D Aufmkolk M Rucholtz S Obertacke U Waydhas C Multiple organ failure still a major cause of morbidity but not mortality in blunt multiple trauma J Trauma 200151835-842 Durham RM Moran JJ Mazuski JE Shapiro MJ Baue AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
It has been suggested that MOF is disappearing owing to advances in trauma and critical care
Levine JH Durham RM Moran J Bauer A Multiple organ failure is it disappearing World J Surg 199620471-473
Recent reports have not demonstrated a consistent change in either the incidence or the mortality rate associated with postinjury MOF Some groups have reported no change in the incidence but a decreased mortality while others have reported both decreased incidence and mortality compared with historical control subjects
Durham RM Moran JJ Mazuski JE Shapiro MJ Bauer AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
Regel G Grotz M Weltner T Sturm JA Tscherne H Pattern of organ failure following severe trauma World J Surg 199620422-429
Orthopaedic Trauma
Open pelvic fractures in addition to the pelvic ring injury are associated with hemorrhage and neurological insult visceral injuries are more common and a high rate of infection is seen Mortality of open pelvic fractures historically approached 50 Control of bleeding is the most important initial measure followed by debridement and packing of open wounds
Open book- widened symphysis pubis Dislocated Rt SI joint Vallier + Jenkins In Trauma Anesthesia 2008
Type 1 fractures occur due to anterior-posterior
compressioncan cause the symphysis pubis to ldquopoprdquo open leading to pubic rami or ldquoopen
bookrdquo fractures A lateral compression fracture type 2 or vertical sheer facture (Type 3) can
also lead to severe bleeding Into the pelvis Pelvic and acetabular surgery are major surgical interventions
Figura 1- Aplicacioacuten de la engrapadora para la reseccioacuten pulmonar en cuntildea Los segmentos a resecar se limitan por medio de la aplicacioacuten de dispositivos de grapado orientados en direcciones perpendiculares tratando de mantener la mayor cantidad de tejido sano
Insercioacuten de engrapadora lineal cortante a traveacutes de los orificios del tracto de la herida pulmonar penetrante
Figura 3- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales con fuga aeacuterea visible
Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales
Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
- Slide 1
- Slide 2
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
- Slide 10
- Slide 11
- Slide 12
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- Slide 31
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Slide 36
- Slide 37
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
Experimental studies have revealed that resuscitation with NS in the setting of massive hemorrhage requires significantly greater volume and is associated with increased physiologic derangements (for example hyperchloremic acidosis and dilutional coagulopathy) and higher mortality as compared with LR Healey MA Davis RE Liu FC Loomis WH Hoyt DB Lactated ringers is superior to normal saline in a model of massive hemorrhage and resuscitation J Trauma 1998 45894-899 Todd SR Malinoski D Muller PJ Schreiber MA Lactated Ringers is superior to normal saline in the resuscitation of uncontrolled hemorrhagic shock J Trauma 2007 62636-639
Reported data from several studies conducted in critically ill patients have indicated that use of colloid solutions has a significant impact on hemorrhage hemostasis and inflammatory response Roberts I Alderson P Bunn F Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2004 CD000567 Vercueil A Grocott MP Mythen MG Physiology pharmacology and rationale for colloid administration for the maintenance of effective hemodynamic stability in critically ill patients Transfus Med Rev 2005 1993-109 Lee CC Chang IJ Yen ZS Effect of different resuscitation fluids on cytokine response in a rat model of hemorrhagic shock Shock 2005 24177-181
Early administration of blood is one potential treatment to decrease the
need for massive crystalloid solution in hemorrhagic shock however the
limited supply of stored blood and potential adverse effects make this
option logistically difficult and possibly harmful
West MA Sha piro MB Nathens AB Johnson JL Moore EE Minei JP Bankey PE Freeman B Harbrecht BG McKinley BA Moore FA Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core-standard operating procedures for clinical care IV Guidelines for transfusion in the trauma patient J Trauma 2006 61436-439
Moore FA McKinley BA Moore EE Nathens AB West M Shapiro MB Bankey P Freeman B Harbrecht BG Johnson JL Minei JP Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core standard operating procedures for clinical care III Guidelines for shock resuscitation J Trauma 2006 6182-89 Spahn DR Cerny V Coats TJ Duranteau J Fernandez-Mondejar E Gordini G Stahel PF Hunt BJ Komadina R Neugebauer E Ozier Y Riddez L Schultz A Vincent JL Rossaint R Task Force for Advanced Bleeding Care in Trauma Management of bleeding following major trauma a European guideline Crit Care 2007 11R17
Transfusion-related risks include possible development of MOF increased
ICU admissions and length of stay increased hospital length of stay and
mortality
Malone DL Dunne J Tracy JK Putnam AT Scalea TM Napolitano LM Blood transfusion independent of shock severity is associated with worse outcome in trauma J Trauma 2003 54898-905
Eastridge BJ Malone D Holcomb JB Early predictors of transfusion and mortality after injury a review of the data-based literature J Trauma 2006 60S20-S25
Napolitano L Cumulative risks of early red blood cell transfusion J Trauma 2006 60S26-S34
Cotton BA Guy JS Morris JA Jr Abumrad NN The cellular metabolic and systemic consequences of aggressive fluid resuscitation strategies Shock 2006 26115-121
uarr hemorrhage + excessive hemodilution due to
uarr Blood Presion darr blood viscosity darr hematocrit
darr clotting factor concentration
Risks of Aggressive Volume Resuscitation
rFVIIaThe use of rFVIIa was associated with improved early and late survival after severe trauma and massive transfusion
rFVIIa was not associated with increased risk of thrombotic events
The Effect of Recombinant Activated Factor VII on Mortality in Combat-Related Casualties With Severe Trauma and Massive Transfusion
bull Philip C Spinella MD Jeremy G Perkins MD Daniel F McLaughlin MD Sarah E Niles MD MPHKurt W Grathwohl MD Alec C Beekley MD Jose Salinas PhD Sumeru Mehta MD Charles E Wade PhDand John B Holcomb MD J of Trauma- Feb 2008bull Dutton et al J Trauma 200457709 Conclusion consider early use of FVIIa in any pt with uncontrolled hemorrhage who has not responded to surgery or blood component therapy
bull Each unit of blood product biologically active + elevates risk of infections + ARDS (SDRA)Chaiwat et al Anesthesiology 2009110351 n=14070 pts NSCOT database retrospective
bull Older blood association whith elevates infection LOS MOSF + death Weinberg et al J Trauma 200865279
TemperatureA temperature lt 96degF or 35degC is associated with an increase in mortality (cardiac arrest SRP higher abnormal plaquelet function) Burch J Denton J Noble R Physiologic rationale for abbreviated laparotomy Surg Clin North Am 1997 77779-82 Trauma patients that are hypothermic are NOT PERFUSING their tissue
The COAGULATION CASCADE is an enzymatic pathway that degrades with temperature and ceases at 92 FGregory JS Francbeum L Towsened MC Incidence and timing of hypothermia in trauma patients undergoing operations J Trauma 1991 31795-800 If the temperature is lower than 33 C the mortality is 100although Beilman and col think itacutes a significant factor for MODS but not for the mortalityBeilman GJ Blondet JJ Early hypothermia in severely injured trauma patients is a significant risk factor for multiple organ dysfunction syndrome but not mortality Ann Surg 2009 May249(5)845-50
Diagnosis done
Damage Control Resuscitation
1 Hypotensive resuscitation
2 Hemostatic resuscitation
Damage control philosophy can be extended to haemostatic resuscitation
Restoring normal coagulation Minimizing crystalloidTraditional resuscitation strategies dilute the already deficient coagulation factors and increase multiple organ failure
The aggressive hemostatic resuscitation should be combined with equally aggressive control of bleeding
Spahn DR Cerny V Management of bleeding following major trauma a European guidelineCrit Care 2007 11(1) R 17
WAIT AND SEE
SURGEON
ABDOMINAL PACKING is a lifesaving technique for temporary control of severe injury and it is used in damage control surgery schedule
Its possible too applying packs in organ-specific techniques (early abdominal packing)
The median survival of the 70 certainly superior to the obtainable survival with immediate surgical repairbullIMMEDIATE FAILURES are substantially due to bleeding especially in underpacking caseREMOTE FAILURES septic and bound at the time of stay (above the 72 hours) and associated by the coexistence of lesions in these situations is possible a MOF syndrome due to excessive intra-abdominal pressure (overpacking) or to an Abdominal Compartment Syndrome
Stagnitti F Bresadola L Calderale SM Coletti M Ribaldi S Salvi PF Schillaci F Abdominal packing indications and method Ann Ital Chir 2003 Sep-Oct74(5)535-42
Benavides C Garciacutea C Apablaza S Rubilar P Ricaurte F Perales C et al Empaquetamiento hepaacutetico permanente con malla de poliglactina en estallido hepaacutetico secundario a Siacutendrome de Hellp Rev Chil Cir 2004 56 275-278 De la Fuente M Mendoza VH Robledo-Oyarzun F Cierre Temporal de la pared abdominal con polietileno Cir Ciruj 2002 70157-63 Serna VH El Siacutendrome Compartamental Abdominal Tesis de Postgrado Meacutexico 2000
When skin approximation is
not possible a temporary silo
is constructed by suturing a 3-
L cystoscopy irrigation bag
(BOGOTAacute BAG) to the skin
edge with a continuous No 2
nylon suture
The method of closure depends on whether skin approximation produces excessive intra-abdominal hypertension
Towel-clip closure of the skin is preferred because it is quick and easy
The second phase is intra-operative reassessment for hemorrhage control 30 minutes after initial abdominal closure in the operating room focusing on restoration of the patients physiological status specifically reversing hypothermia and coagulopathy
WE CAN HEAR THE HEMORRHAGE
The abdomen is then reopened and assessed for adequacy of hemostasis and for existence of residual mechanical bleeding This practice has allowed surgeons to minimize both early return to the operating room for ongoing hemorrhage and the amount of packing necessary for hemostasis With bleeding effectively controlled the abdomen is reclosed
The patient is transferred to the ICU for continued physiologic restoration in the third phase
Once coagulopathy hypothermia and acidosis have been corrected the patient can be returned to the operating room for definitive management of the injuries in the fourth phase
48-72 h after first surgery
COMPLICATIONS OF DAMAGE CONTROL LAPAROTOMY
1) ACS Acute Compartmental Syndrome
2) ARDS Acute Respiratory Distress of the Adult
3) MOF Multiple organ failure
4) DEATH
ABDOMINAL COMPARTMENT SYNDROME is defined as an intra-abdominal pressure of greater than 20 cm H2O with evidence of impaired organ function ie elevated peak airway pressures (gt45 cm
H2O) oliguria (lt05 mLkg per hour) or cardiovascular dysfunction
(hypotension despite adequate volume resuscitation or if a pulmonary artery catheter is present oxygen delivery index [calculated as milliliters of oxygen per minute per meter squared] of 600) Intra-abdominal pressure was measured indirectly using an indwelling Foley catheter as previously described
Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13 Damage control surgery in the abdomen an approach for the management of severe injured patientsGermanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis NNuffield Department of Surgery John Radcliffe Hospital Oxford UK Curr Opin Crit Care 2006 Aug12(4)346-50 Damage-control laparotomy Lee JC Peitzman AB Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA
ABDOMINAL COMPARTMENT SYNDROME occurred in 17 (33) of
52 Patients undergoing damage-control laparotomy and was
associated with a much higher incidence of ARDS and MOF (71 vs
31 without ACS P = 02)
More importantly our study suggests that primary fascial closure at
the termination of the initial damage-control laparotomy contributes to
the development of ACS as well as subsequent organ failure
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal ypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
Mayberry JC Mullins RJ Crass RA Trunkey DD Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure Arch Surg 1997132957-962
bull MOF Multiple organ failure
Seems to be a major source of postinjury morbidity and the leading cause of in-hospital mortality despite more than 25 years of intense investigation
Eiseman B Beart R Norton L Multiple organ failure Surg Gynecol Obstet 1977144323-326
Bauer AE Durham R Faist E Systemic inflammatory response syndrome (SIRS) multiple organ dysfunction syndrome (MODS) multiple organ failure (MOF) are we winning the battle Shock 19981079-89
The current pathophysiologic model of MOF focuses on uncontrolled systemic
hyperinflammation as a unifying concept following a variety of insults
Moore FA Moore EE Evolving concepts in the pathogenesis of postinjury multiple organ failure Surg Clin North Am 199575257-277
Goris RJ te Boekhorst TP Nuytinck JK Gimbrere JS Multiple-organ failure generalized autodestructive inflammation Arch Surg 19851201109-1115
Nuytinck HK Offermans XJ Kubat K Goris JA Whole-body inflammation in trauma patients an autopsy study Arch Surg 19881231519-1524
Examples that improve the prognosis of MOF include damage control surgery recognition of abdominal compartment syndrome lung protective ventilation
strategies and tight glucose level control
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal hypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
The Acute Respiratory Distress Syndrome Network Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome N Engl J Med 20003421301-1308
Amato MB Barbas CS Medeiros DM et al Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome N Engl J Med 1998338347-354
Van den Berghe G Wouters P Weekers F et al Intensive insulin therapy in the critically ill patients N Engl J Med 20013451359-1367
The incidence of postinjury MOF has been reported to be between 7 and 66 with an associated mortality rate between 31 and 80
Fry DE Pearlstein L Fulton RL Polk HC Jr Multiple system organ failure the role of uncontrolled infection Arch Surg 1980115136-140
Regel G Lobenhoffer P Grotz M Pape HC Lehmann U Tscherne H Treatment results of patients with multiple trauma an analysis of 3406 cases treated between 1972 and 1991 at a German level I trauma center J Trauma 19953870-78
Sauaia A Moore FA Moore EE Norris JM Lezotte DC Hamman RF Multiple organ failure can be predicted as early as 12 hours after injury J Trauma 199845291-303
Nast-Kolb D Aufmkolk M Rucholtz S Obertacke U Waydhas C Multiple organ failure still a major cause of morbidity but not mortality in blunt multiple trauma J Trauma 200151835-842 Durham RM Moran JJ Mazuski JE Shapiro MJ Baue AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
It has been suggested that MOF is disappearing owing to advances in trauma and critical care
Levine JH Durham RM Moran J Bauer A Multiple organ failure is it disappearing World J Surg 199620471-473
Recent reports have not demonstrated a consistent change in either the incidence or the mortality rate associated with postinjury MOF Some groups have reported no change in the incidence but a decreased mortality while others have reported both decreased incidence and mortality compared with historical control subjects
Durham RM Moran JJ Mazuski JE Shapiro MJ Bauer AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
Regel G Grotz M Weltner T Sturm JA Tscherne H Pattern of organ failure following severe trauma World J Surg 199620422-429
Orthopaedic Trauma
Open pelvic fractures in addition to the pelvic ring injury are associated with hemorrhage and neurological insult visceral injuries are more common and a high rate of infection is seen Mortality of open pelvic fractures historically approached 50 Control of bleeding is the most important initial measure followed by debridement and packing of open wounds
Open book- widened symphysis pubis Dislocated Rt SI joint Vallier + Jenkins In Trauma Anesthesia 2008
Type 1 fractures occur due to anterior-posterior
compressioncan cause the symphysis pubis to ldquopoprdquo open leading to pubic rami or ldquoopen
bookrdquo fractures A lateral compression fracture type 2 or vertical sheer facture (Type 3) can
also lead to severe bleeding Into the pelvis Pelvic and acetabular surgery are major surgical interventions
Figura 1- Aplicacioacuten de la engrapadora para la reseccioacuten pulmonar en cuntildea Los segmentos a resecar se limitan por medio de la aplicacioacuten de dispositivos de grapado orientados en direcciones perpendiculares tratando de mantener la mayor cantidad de tejido sano
Insercioacuten de engrapadora lineal cortante a traveacutes de los orificios del tracto de la herida pulmonar penetrante
Figura 3- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales con fuga aeacuterea visible
Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales
Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
- Slide 1
- Slide 2
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
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- Slide 31
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- Slide 35
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- Slide 37
- Slide 38
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- Slide 41
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- Slide 57
- Slide 58
- Slide 59
-
Early administration of blood is one potential treatment to decrease the
need for massive crystalloid solution in hemorrhagic shock however the
limited supply of stored blood and potential adverse effects make this
option logistically difficult and possibly harmful
West MA Sha piro MB Nathens AB Johnson JL Moore EE Minei JP Bankey PE Freeman B Harbrecht BG McKinley BA Moore FA Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core-standard operating procedures for clinical care IV Guidelines for transfusion in the trauma patient J Trauma 2006 61436-439
Moore FA McKinley BA Moore EE Nathens AB West M Shapiro MB Bankey P Freeman B Harbrecht BG Johnson JL Minei JP Maier RV Inflammation and the host response to injury a large-scale collaborative project patient-oriented research core standard operating procedures for clinical care III Guidelines for shock resuscitation J Trauma 2006 6182-89 Spahn DR Cerny V Coats TJ Duranteau J Fernandez-Mondejar E Gordini G Stahel PF Hunt BJ Komadina R Neugebauer E Ozier Y Riddez L Schultz A Vincent JL Rossaint R Task Force for Advanced Bleeding Care in Trauma Management of bleeding following major trauma a European guideline Crit Care 2007 11R17
Transfusion-related risks include possible development of MOF increased
ICU admissions and length of stay increased hospital length of stay and
mortality
Malone DL Dunne J Tracy JK Putnam AT Scalea TM Napolitano LM Blood transfusion independent of shock severity is associated with worse outcome in trauma J Trauma 2003 54898-905
Eastridge BJ Malone D Holcomb JB Early predictors of transfusion and mortality after injury a review of the data-based literature J Trauma 2006 60S20-S25
Napolitano L Cumulative risks of early red blood cell transfusion J Trauma 2006 60S26-S34
Cotton BA Guy JS Morris JA Jr Abumrad NN The cellular metabolic and systemic consequences of aggressive fluid resuscitation strategies Shock 2006 26115-121
uarr hemorrhage + excessive hemodilution due to
uarr Blood Presion darr blood viscosity darr hematocrit
darr clotting factor concentration
Risks of Aggressive Volume Resuscitation
rFVIIaThe use of rFVIIa was associated with improved early and late survival after severe trauma and massive transfusion
rFVIIa was not associated with increased risk of thrombotic events
The Effect of Recombinant Activated Factor VII on Mortality in Combat-Related Casualties With Severe Trauma and Massive Transfusion
bull Philip C Spinella MD Jeremy G Perkins MD Daniel F McLaughlin MD Sarah E Niles MD MPHKurt W Grathwohl MD Alec C Beekley MD Jose Salinas PhD Sumeru Mehta MD Charles E Wade PhDand John B Holcomb MD J of Trauma- Feb 2008bull Dutton et al J Trauma 200457709 Conclusion consider early use of FVIIa in any pt with uncontrolled hemorrhage who has not responded to surgery or blood component therapy
bull Each unit of blood product biologically active + elevates risk of infections + ARDS (SDRA)Chaiwat et al Anesthesiology 2009110351 n=14070 pts NSCOT database retrospective
bull Older blood association whith elevates infection LOS MOSF + death Weinberg et al J Trauma 200865279
TemperatureA temperature lt 96degF or 35degC is associated with an increase in mortality (cardiac arrest SRP higher abnormal plaquelet function) Burch J Denton J Noble R Physiologic rationale for abbreviated laparotomy Surg Clin North Am 1997 77779-82 Trauma patients that are hypothermic are NOT PERFUSING their tissue
The COAGULATION CASCADE is an enzymatic pathway that degrades with temperature and ceases at 92 FGregory JS Francbeum L Towsened MC Incidence and timing of hypothermia in trauma patients undergoing operations J Trauma 1991 31795-800 If the temperature is lower than 33 C the mortality is 100although Beilman and col think itacutes a significant factor for MODS but not for the mortalityBeilman GJ Blondet JJ Early hypothermia in severely injured trauma patients is a significant risk factor for multiple organ dysfunction syndrome but not mortality Ann Surg 2009 May249(5)845-50
Diagnosis done
Damage Control Resuscitation
1 Hypotensive resuscitation
2 Hemostatic resuscitation
Damage control philosophy can be extended to haemostatic resuscitation
Restoring normal coagulation Minimizing crystalloidTraditional resuscitation strategies dilute the already deficient coagulation factors and increase multiple organ failure
The aggressive hemostatic resuscitation should be combined with equally aggressive control of bleeding
Spahn DR Cerny V Management of bleeding following major trauma a European guidelineCrit Care 2007 11(1) R 17
WAIT AND SEE
SURGEON
ABDOMINAL PACKING is a lifesaving technique for temporary control of severe injury and it is used in damage control surgery schedule
Its possible too applying packs in organ-specific techniques (early abdominal packing)
The median survival of the 70 certainly superior to the obtainable survival with immediate surgical repairbullIMMEDIATE FAILURES are substantially due to bleeding especially in underpacking caseREMOTE FAILURES septic and bound at the time of stay (above the 72 hours) and associated by the coexistence of lesions in these situations is possible a MOF syndrome due to excessive intra-abdominal pressure (overpacking) or to an Abdominal Compartment Syndrome
Stagnitti F Bresadola L Calderale SM Coletti M Ribaldi S Salvi PF Schillaci F Abdominal packing indications and method Ann Ital Chir 2003 Sep-Oct74(5)535-42
Benavides C Garciacutea C Apablaza S Rubilar P Ricaurte F Perales C et al Empaquetamiento hepaacutetico permanente con malla de poliglactina en estallido hepaacutetico secundario a Siacutendrome de Hellp Rev Chil Cir 2004 56 275-278 De la Fuente M Mendoza VH Robledo-Oyarzun F Cierre Temporal de la pared abdominal con polietileno Cir Ciruj 2002 70157-63 Serna VH El Siacutendrome Compartamental Abdominal Tesis de Postgrado Meacutexico 2000
When skin approximation is
not possible a temporary silo
is constructed by suturing a 3-
L cystoscopy irrigation bag
(BOGOTAacute BAG) to the skin
edge with a continuous No 2
nylon suture
The method of closure depends on whether skin approximation produces excessive intra-abdominal hypertension
Towel-clip closure of the skin is preferred because it is quick and easy
The second phase is intra-operative reassessment for hemorrhage control 30 minutes after initial abdominal closure in the operating room focusing on restoration of the patients physiological status specifically reversing hypothermia and coagulopathy
WE CAN HEAR THE HEMORRHAGE
The abdomen is then reopened and assessed for adequacy of hemostasis and for existence of residual mechanical bleeding This practice has allowed surgeons to minimize both early return to the operating room for ongoing hemorrhage and the amount of packing necessary for hemostasis With bleeding effectively controlled the abdomen is reclosed
The patient is transferred to the ICU for continued physiologic restoration in the third phase
Once coagulopathy hypothermia and acidosis have been corrected the patient can be returned to the operating room for definitive management of the injuries in the fourth phase
48-72 h after first surgery
COMPLICATIONS OF DAMAGE CONTROL LAPAROTOMY
1) ACS Acute Compartmental Syndrome
2) ARDS Acute Respiratory Distress of the Adult
3) MOF Multiple organ failure
4) DEATH
ABDOMINAL COMPARTMENT SYNDROME is defined as an intra-abdominal pressure of greater than 20 cm H2O with evidence of impaired organ function ie elevated peak airway pressures (gt45 cm
H2O) oliguria (lt05 mLkg per hour) or cardiovascular dysfunction
(hypotension despite adequate volume resuscitation or if a pulmonary artery catheter is present oxygen delivery index [calculated as milliliters of oxygen per minute per meter squared] of 600) Intra-abdominal pressure was measured indirectly using an indwelling Foley catheter as previously described
Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13 Damage control surgery in the abdomen an approach for the management of severe injured patientsGermanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis NNuffield Department of Surgery John Radcliffe Hospital Oxford UK Curr Opin Crit Care 2006 Aug12(4)346-50 Damage-control laparotomy Lee JC Peitzman AB Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA
ABDOMINAL COMPARTMENT SYNDROME occurred in 17 (33) of
52 Patients undergoing damage-control laparotomy and was
associated with a much higher incidence of ARDS and MOF (71 vs
31 without ACS P = 02)
More importantly our study suggests that primary fascial closure at
the termination of the initial damage-control laparotomy contributes to
the development of ACS as well as subsequent organ failure
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal ypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
Mayberry JC Mullins RJ Crass RA Trunkey DD Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure Arch Surg 1997132957-962
bull MOF Multiple organ failure
Seems to be a major source of postinjury morbidity and the leading cause of in-hospital mortality despite more than 25 years of intense investigation
Eiseman B Beart R Norton L Multiple organ failure Surg Gynecol Obstet 1977144323-326
Bauer AE Durham R Faist E Systemic inflammatory response syndrome (SIRS) multiple organ dysfunction syndrome (MODS) multiple organ failure (MOF) are we winning the battle Shock 19981079-89
The current pathophysiologic model of MOF focuses on uncontrolled systemic
hyperinflammation as a unifying concept following a variety of insults
Moore FA Moore EE Evolving concepts in the pathogenesis of postinjury multiple organ failure Surg Clin North Am 199575257-277
Goris RJ te Boekhorst TP Nuytinck JK Gimbrere JS Multiple-organ failure generalized autodestructive inflammation Arch Surg 19851201109-1115
Nuytinck HK Offermans XJ Kubat K Goris JA Whole-body inflammation in trauma patients an autopsy study Arch Surg 19881231519-1524
Examples that improve the prognosis of MOF include damage control surgery recognition of abdominal compartment syndrome lung protective ventilation
strategies and tight glucose level control
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal hypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
The Acute Respiratory Distress Syndrome Network Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome N Engl J Med 20003421301-1308
Amato MB Barbas CS Medeiros DM et al Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome N Engl J Med 1998338347-354
Van den Berghe G Wouters P Weekers F et al Intensive insulin therapy in the critically ill patients N Engl J Med 20013451359-1367
The incidence of postinjury MOF has been reported to be between 7 and 66 with an associated mortality rate between 31 and 80
Fry DE Pearlstein L Fulton RL Polk HC Jr Multiple system organ failure the role of uncontrolled infection Arch Surg 1980115136-140
Regel G Lobenhoffer P Grotz M Pape HC Lehmann U Tscherne H Treatment results of patients with multiple trauma an analysis of 3406 cases treated between 1972 and 1991 at a German level I trauma center J Trauma 19953870-78
Sauaia A Moore FA Moore EE Norris JM Lezotte DC Hamman RF Multiple organ failure can be predicted as early as 12 hours after injury J Trauma 199845291-303
Nast-Kolb D Aufmkolk M Rucholtz S Obertacke U Waydhas C Multiple organ failure still a major cause of morbidity but not mortality in blunt multiple trauma J Trauma 200151835-842 Durham RM Moran JJ Mazuski JE Shapiro MJ Baue AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
It has been suggested that MOF is disappearing owing to advances in trauma and critical care
Levine JH Durham RM Moran J Bauer A Multiple organ failure is it disappearing World J Surg 199620471-473
Recent reports have not demonstrated a consistent change in either the incidence or the mortality rate associated with postinjury MOF Some groups have reported no change in the incidence but a decreased mortality while others have reported both decreased incidence and mortality compared with historical control subjects
Durham RM Moran JJ Mazuski JE Shapiro MJ Bauer AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
Regel G Grotz M Weltner T Sturm JA Tscherne H Pattern of organ failure following severe trauma World J Surg 199620422-429
Orthopaedic Trauma
Open pelvic fractures in addition to the pelvic ring injury are associated with hemorrhage and neurological insult visceral injuries are more common and a high rate of infection is seen Mortality of open pelvic fractures historically approached 50 Control of bleeding is the most important initial measure followed by debridement and packing of open wounds
Open book- widened symphysis pubis Dislocated Rt SI joint Vallier + Jenkins In Trauma Anesthesia 2008
Type 1 fractures occur due to anterior-posterior
compressioncan cause the symphysis pubis to ldquopoprdquo open leading to pubic rami or ldquoopen
bookrdquo fractures A lateral compression fracture type 2 or vertical sheer facture (Type 3) can
also lead to severe bleeding Into the pelvis Pelvic and acetabular surgery are major surgical interventions
Figura 1- Aplicacioacuten de la engrapadora para la reseccioacuten pulmonar en cuntildea Los segmentos a resecar se limitan por medio de la aplicacioacuten de dispositivos de grapado orientados en direcciones perpendiculares tratando de mantener la mayor cantidad de tejido sano
Insercioacuten de engrapadora lineal cortante a traveacutes de los orificios del tracto de la herida pulmonar penetrante
Figura 3- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales con fuga aeacuterea visible
Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales
Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
- Slide 1
- Slide 2
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
- Slide 10
- Slide 11
- Slide 12
- Slide 13
- Slide 14
- Slide 15
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- Slide 24
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- Slide 27
- Slide 28
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- Slide 31
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- Slide 33
- Slide 34
- Slide 35
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- Slide 37
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
Transfusion-related risks include possible development of MOF increased
ICU admissions and length of stay increased hospital length of stay and
mortality
Malone DL Dunne J Tracy JK Putnam AT Scalea TM Napolitano LM Blood transfusion independent of shock severity is associated with worse outcome in trauma J Trauma 2003 54898-905
Eastridge BJ Malone D Holcomb JB Early predictors of transfusion and mortality after injury a review of the data-based literature J Trauma 2006 60S20-S25
Napolitano L Cumulative risks of early red blood cell transfusion J Trauma 2006 60S26-S34
Cotton BA Guy JS Morris JA Jr Abumrad NN The cellular metabolic and systemic consequences of aggressive fluid resuscitation strategies Shock 2006 26115-121
uarr hemorrhage + excessive hemodilution due to
uarr Blood Presion darr blood viscosity darr hematocrit
darr clotting factor concentration
Risks of Aggressive Volume Resuscitation
rFVIIaThe use of rFVIIa was associated with improved early and late survival after severe trauma and massive transfusion
rFVIIa was not associated with increased risk of thrombotic events
The Effect of Recombinant Activated Factor VII on Mortality in Combat-Related Casualties With Severe Trauma and Massive Transfusion
bull Philip C Spinella MD Jeremy G Perkins MD Daniel F McLaughlin MD Sarah E Niles MD MPHKurt W Grathwohl MD Alec C Beekley MD Jose Salinas PhD Sumeru Mehta MD Charles E Wade PhDand John B Holcomb MD J of Trauma- Feb 2008bull Dutton et al J Trauma 200457709 Conclusion consider early use of FVIIa in any pt with uncontrolled hemorrhage who has not responded to surgery or blood component therapy
bull Each unit of blood product biologically active + elevates risk of infections + ARDS (SDRA)Chaiwat et al Anesthesiology 2009110351 n=14070 pts NSCOT database retrospective
bull Older blood association whith elevates infection LOS MOSF + death Weinberg et al J Trauma 200865279
TemperatureA temperature lt 96degF or 35degC is associated with an increase in mortality (cardiac arrest SRP higher abnormal plaquelet function) Burch J Denton J Noble R Physiologic rationale for abbreviated laparotomy Surg Clin North Am 1997 77779-82 Trauma patients that are hypothermic are NOT PERFUSING their tissue
The COAGULATION CASCADE is an enzymatic pathway that degrades with temperature and ceases at 92 FGregory JS Francbeum L Towsened MC Incidence and timing of hypothermia in trauma patients undergoing operations J Trauma 1991 31795-800 If the temperature is lower than 33 C the mortality is 100although Beilman and col think itacutes a significant factor for MODS but not for the mortalityBeilman GJ Blondet JJ Early hypothermia in severely injured trauma patients is a significant risk factor for multiple organ dysfunction syndrome but not mortality Ann Surg 2009 May249(5)845-50
Diagnosis done
Damage Control Resuscitation
1 Hypotensive resuscitation
2 Hemostatic resuscitation
Damage control philosophy can be extended to haemostatic resuscitation
Restoring normal coagulation Minimizing crystalloidTraditional resuscitation strategies dilute the already deficient coagulation factors and increase multiple organ failure
The aggressive hemostatic resuscitation should be combined with equally aggressive control of bleeding
Spahn DR Cerny V Management of bleeding following major trauma a European guidelineCrit Care 2007 11(1) R 17
WAIT AND SEE
SURGEON
ABDOMINAL PACKING is a lifesaving technique for temporary control of severe injury and it is used in damage control surgery schedule
Its possible too applying packs in organ-specific techniques (early abdominal packing)
The median survival of the 70 certainly superior to the obtainable survival with immediate surgical repairbullIMMEDIATE FAILURES are substantially due to bleeding especially in underpacking caseREMOTE FAILURES septic and bound at the time of stay (above the 72 hours) and associated by the coexistence of lesions in these situations is possible a MOF syndrome due to excessive intra-abdominal pressure (overpacking) or to an Abdominal Compartment Syndrome
Stagnitti F Bresadola L Calderale SM Coletti M Ribaldi S Salvi PF Schillaci F Abdominal packing indications and method Ann Ital Chir 2003 Sep-Oct74(5)535-42
Benavides C Garciacutea C Apablaza S Rubilar P Ricaurte F Perales C et al Empaquetamiento hepaacutetico permanente con malla de poliglactina en estallido hepaacutetico secundario a Siacutendrome de Hellp Rev Chil Cir 2004 56 275-278 De la Fuente M Mendoza VH Robledo-Oyarzun F Cierre Temporal de la pared abdominal con polietileno Cir Ciruj 2002 70157-63 Serna VH El Siacutendrome Compartamental Abdominal Tesis de Postgrado Meacutexico 2000
When skin approximation is
not possible a temporary silo
is constructed by suturing a 3-
L cystoscopy irrigation bag
(BOGOTAacute BAG) to the skin
edge with a continuous No 2
nylon suture
The method of closure depends on whether skin approximation produces excessive intra-abdominal hypertension
Towel-clip closure of the skin is preferred because it is quick and easy
The second phase is intra-operative reassessment for hemorrhage control 30 minutes after initial abdominal closure in the operating room focusing on restoration of the patients physiological status specifically reversing hypothermia and coagulopathy
WE CAN HEAR THE HEMORRHAGE
The abdomen is then reopened and assessed for adequacy of hemostasis and for existence of residual mechanical bleeding This practice has allowed surgeons to minimize both early return to the operating room for ongoing hemorrhage and the amount of packing necessary for hemostasis With bleeding effectively controlled the abdomen is reclosed
The patient is transferred to the ICU for continued physiologic restoration in the third phase
Once coagulopathy hypothermia and acidosis have been corrected the patient can be returned to the operating room for definitive management of the injuries in the fourth phase
48-72 h after first surgery
COMPLICATIONS OF DAMAGE CONTROL LAPAROTOMY
1) ACS Acute Compartmental Syndrome
2) ARDS Acute Respiratory Distress of the Adult
3) MOF Multiple organ failure
4) DEATH
ABDOMINAL COMPARTMENT SYNDROME is defined as an intra-abdominal pressure of greater than 20 cm H2O with evidence of impaired organ function ie elevated peak airway pressures (gt45 cm
H2O) oliguria (lt05 mLkg per hour) or cardiovascular dysfunction
(hypotension despite adequate volume resuscitation or if a pulmonary artery catheter is present oxygen delivery index [calculated as milliliters of oxygen per minute per meter squared] of 600) Intra-abdominal pressure was measured indirectly using an indwelling Foley catheter as previously described
Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13 Damage control surgery in the abdomen an approach for the management of severe injured patientsGermanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis NNuffield Department of Surgery John Radcliffe Hospital Oxford UK Curr Opin Crit Care 2006 Aug12(4)346-50 Damage-control laparotomy Lee JC Peitzman AB Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA
ABDOMINAL COMPARTMENT SYNDROME occurred in 17 (33) of
52 Patients undergoing damage-control laparotomy and was
associated with a much higher incidence of ARDS and MOF (71 vs
31 without ACS P = 02)
More importantly our study suggests that primary fascial closure at
the termination of the initial damage-control laparotomy contributes to
the development of ACS as well as subsequent organ failure
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal ypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
Mayberry JC Mullins RJ Crass RA Trunkey DD Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure Arch Surg 1997132957-962
bull MOF Multiple organ failure
Seems to be a major source of postinjury morbidity and the leading cause of in-hospital mortality despite more than 25 years of intense investigation
Eiseman B Beart R Norton L Multiple organ failure Surg Gynecol Obstet 1977144323-326
Bauer AE Durham R Faist E Systemic inflammatory response syndrome (SIRS) multiple organ dysfunction syndrome (MODS) multiple organ failure (MOF) are we winning the battle Shock 19981079-89
The current pathophysiologic model of MOF focuses on uncontrolled systemic
hyperinflammation as a unifying concept following a variety of insults
Moore FA Moore EE Evolving concepts in the pathogenesis of postinjury multiple organ failure Surg Clin North Am 199575257-277
Goris RJ te Boekhorst TP Nuytinck JK Gimbrere JS Multiple-organ failure generalized autodestructive inflammation Arch Surg 19851201109-1115
Nuytinck HK Offermans XJ Kubat K Goris JA Whole-body inflammation in trauma patients an autopsy study Arch Surg 19881231519-1524
Examples that improve the prognosis of MOF include damage control surgery recognition of abdominal compartment syndrome lung protective ventilation
strategies and tight glucose level control
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal hypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
The Acute Respiratory Distress Syndrome Network Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome N Engl J Med 20003421301-1308
Amato MB Barbas CS Medeiros DM et al Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome N Engl J Med 1998338347-354
Van den Berghe G Wouters P Weekers F et al Intensive insulin therapy in the critically ill patients N Engl J Med 20013451359-1367
The incidence of postinjury MOF has been reported to be between 7 and 66 with an associated mortality rate between 31 and 80
Fry DE Pearlstein L Fulton RL Polk HC Jr Multiple system organ failure the role of uncontrolled infection Arch Surg 1980115136-140
Regel G Lobenhoffer P Grotz M Pape HC Lehmann U Tscherne H Treatment results of patients with multiple trauma an analysis of 3406 cases treated between 1972 and 1991 at a German level I trauma center J Trauma 19953870-78
Sauaia A Moore FA Moore EE Norris JM Lezotte DC Hamman RF Multiple organ failure can be predicted as early as 12 hours after injury J Trauma 199845291-303
Nast-Kolb D Aufmkolk M Rucholtz S Obertacke U Waydhas C Multiple organ failure still a major cause of morbidity but not mortality in blunt multiple trauma J Trauma 200151835-842 Durham RM Moran JJ Mazuski JE Shapiro MJ Baue AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
It has been suggested that MOF is disappearing owing to advances in trauma and critical care
Levine JH Durham RM Moran J Bauer A Multiple organ failure is it disappearing World J Surg 199620471-473
Recent reports have not demonstrated a consistent change in either the incidence or the mortality rate associated with postinjury MOF Some groups have reported no change in the incidence but a decreased mortality while others have reported both decreased incidence and mortality compared with historical control subjects
Durham RM Moran JJ Mazuski JE Shapiro MJ Bauer AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
Regel G Grotz M Weltner T Sturm JA Tscherne H Pattern of organ failure following severe trauma World J Surg 199620422-429
Orthopaedic Trauma
Open pelvic fractures in addition to the pelvic ring injury are associated with hemorrhage and neurological insult visceral injuries are more common and a high rate of infection is seen Mortality of open pelvic fractures historically approached 50 Control of bleeding is the most important initial measure followed by debridement and packing of open wounds
Open book- widened symphysis pubis Dislocated Rt SI joint Vallier + Jenkins In Trauma Anesthesia 2008
Type 1 fractures occur due to anterior-posterior
compressioncan cause the symphysis pubis to ldquopoprdquo open leading to pubic rami or ldquoopen
bookrdquo fractures A lateral compression fracture type 2 or vertical sheer facture (Type 3) can
also lead to severe bleeding Into the pelvis Pelvic and acetabular surgery are major surgical interventions
Figura 1- Aplicacioacuten de la engrapadora para la reseccioacuten pulmonar en cuntildea Los segmentos a resecar se limitan por medio de la aplicacioacuten de dispositivos de grapado orientados en direcciones perpendiculares tratando de mantener la mayor cantidad de tejido sano
Insercioacuten de engrapadora lineal cortante a traveacutes de los orificios del tracto de la herida pulmonar penetrante
Figura 3- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales con fuga aeacuterea visible
Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales
Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
- Slide 1
- Slide 2
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
- Slide 10
- Slide 11
- Slide 12
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
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- Slide 19
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- Slide 21
- Slide 22
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- Slide 31
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Slide 36
- Slide 37
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
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- Slide 48
- Slide 49
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- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
uarr hemorrhage + excessive hemodilution due to
uarr Blood Presion darr blood viscosity darr hematocrit
darr clotting factor concentration
Risks of Aggressive Volume Resuscitation
rFVIIaThe use of rFVIIa was associated with improved early and late survival after severe trauma and massive transfusion
rFVIIa was not associated with increased risk of thrombotic events
The Effect of Recombinant Activated Factor VII on Mortality in Combat-Related Casualties With Severe Trauma and Massive Transfusion
bull Philip C Spinella MD Jeremy G Perkins MD Daniel F McLaughlin MD Sarah E Niles MD MPHKurt W Grathwohl MD Alec C Beekley MD Jose Salinas PhD Sumeru Mehta MD Charles E Wade PhDand John B Holcomb MD J of Trauma- Feb 2008bull Dutton et al J Trauma 200457709 Conclusion consider early use of FVIIa in any pt with uncontrolled hemorrhage who has not responded to surgery or blood component therapy
bull Each unit of blood product biologically active + elevates risk of infections + ARDS (SDRA)Chaiwat et al Anesthesiology 2009110351 n=14070 pts NSCOT database retrospective
bull Older blood association whith elevates infection LOS MOSF + death Weinberg et al J Trauma 200865279
TemperatureA temperature lt 96degF or 35degC is associated with an increase in mortality (cardiac arrest SRP higher abnormal plaquelet function) Burch J Denton J Noble R Physiologic rationale for abbreviated laparotomy Surg Clin North Am 1997 77779-82 Trauma patients that are hypothermic are NOT PERFUSING their tissue
The COAGULATION CASCADE is an enzymatic pathway that degrades with temperature and ceases at 92 FGregory JS Francbeum L Towsened MC Incidence and timing of hypothermia in trauma patients undergoing operations J Trauma 1991 31795-800 If the temperature is lower than 33 C the mortality is 100although Beilman and col think itacutes a significant factor for MODS but not for the mortalityBeilman GJ Blondet JJ Early hypothermia in severely injured trauma patients is a significant risk factor for multiple organ dysfunction syndrome but not mortality Ann Surg 2009 May249(5)845-50
Diagnosis done
Damage Control Resuscitation
1 Hypotensive resuscitation
2 Hemostatic resuscitation
Damage control philosophy can be extended to haemostatic resuscitation
Restoring normal coagulation Minimizing crystalloidTraditional resuscitation strategies dilute the already deficient coagulation factors and increase multiple organ failure
The aggressive hemostatic resuscitation should be combined with equally aggressive control of bleeding
Spahn DR Cerny V Management of bleeding following major trauma a European guidelineCrit Care 2007 11(1) R 17
WAIT AND SEE
SURGEON
ABDOMINAL PACKING is a lifesaving technique for temporary control of severe injury and it is used in damage control surgery schedule
Its possible too applying packs in organ-specific techniques (early abdominal packing)
The median survival of the 70 certainly superior to the obtainable survival with immediate surgical repairbullIMMEDIATE FAILURES are substantially due to bleeding especially in underpacking caseREMOTE FAILURES septic and bound at the time of stay (above the 72 hours) and associated by the coexistence of lesions in these situations is possible a MOF syndrome due to excessive intra-abdominal pressure (overpacking) or to an Abdominal Compartment Syndrome
Stagnitti F Bresadola L Calderale SM Coletti M Ribaldi S Salvi PF Schillaci F Abdominal packing indications and method Ann Ital Chir 2003 Sep-Oct74(5)535-42
Benavides C Garciacutea C Apablaza S Rubilar P Ricaurte F Perales C et al Empaquetamiento hepaacutetico permanente con malla de poliglactina en estallido hepaacutetico secundario a Siacutendrome de Hellp Rev Chil Cir 2004 56 275-278 De la Fuente M Mendoza VH Robledo-Oyarzun F Cierre Temporal de la pared abdominal con polietileno Cir Ciruj 2002 70157-63 Serna VH El Siacutendrome Compartamental Abdominal Tesis de Postgrado Meacutexico 2000
When skin approximation is
not possible a temporary silo
is constructed by suturing a 3-
L cystoscopy irrigation bag
(BOGOTAacute BAG) to the skin
edge with a continuous No 2
nylon suture
The method of closure depends on whether skin approximation produces excessive intra-abdominal hypertension
Towel-clip closure of the skin is preferred because it is quick and easy
The second phase is intra-operative reassessment for hemorrhage control 30 minutes after initial abdominal closure in the operating room focusing on restoration of the patients physiological status specifically reversing hypothermia and coagulopathy
WE CAN HEAR THE HEMORRHAGE
The abdomen is then reopened and assessed for adequacy of hemostasis and for existence of residual mechanical bleeding This practice has allowed surgeons to minimize both early return to the operating room for ongoing hemorrhage and the amount of packing necessary for hemostasis With bleeding effectively controlled the abdomen is reclosed
The patient is transferred to the ICU for continued physiologic restoration in the third phase
Once coagulopathy hypothermia and acidosis have been corrected the patient can be returned to the operating room for definitive management of the injuries in the fourth phase
48-72 h after first surgery
COMPLICATIONS OF DAMAGE CONTROL LAPAROTOMY
1) ACS Acute Compartmental Syndrome
2) ARDS Acute Respiratory Distress of the Adult
3) MOF Multiple organ failure
4) DEATH
ABDOMINAL COMPARTMENT SYNDROME is defined as an intra-abdominal pressure of greater than 20 cm H2O with evidence of impaired organ function ie elevated peak airway pressures (gt45 cm
H2O) oliguria (lt05 mLkg per hour) or cardiovascular dysfunction
(hypotension despite adequate volume resuscitation or if a pulmonary artery catheter is present oxygen delivery index [calculated as milliliters of oxygen per minute per meter squared] of 600) Intra-abdominal pressure was measured indirectly using an indwelling Foley catheter as previously described
Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13 Damage control surgery in the abdomen an approach for the management of severe injured patientsGermanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis NNuffield Department of Surgery John Radcliffe Hospital Oxford UK Curr Opin Crit Care 2006 Aug12(4)346-50 Damage-control laparotomy Lee JC Peitzman AB Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA
ABDOMINAL COMPARTMENT SYNDROME occurred in 17 (33) of
52 Patients undergoing damage-control laparotomy and was
associated with a much higher incidence of ARDS and MOF (71 vs
31 without ACS P = 02)
More importantly our study suggests that primary fascial closure at
the termination of the initial damage-control laparotomy contributes to
the development of ACS as well as subsequent organ failure
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal ypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
Mayberry JC Mullins RJ Crass RA Trunkey DD Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure Arch Surg 1997132957-962
bull MOF Multiple organ failure
Seems to be a major source of postinjury morbidity and the leading cause of in-hospital mortality despite more than 25 years of intense investigation
Eiseman B Beart R Norton L Multiple organ failure Surg Gynecol Obstet 1977144323-326
Bauer AE Durham R Faist E Systemic inflammatory response syndrome (SIRS) multiple organ dysfunction syndrome (MODS) multiple organ failure (MOF) are we winning the battle Shock 19981079-89
The current pathophysiologic model of MOF focuses on uncontrolled systemic
hyperinflammation as a unifying concept following a variety of insults
Moore FA Moore EE Evolving concepts in the pathogenesis of postinjury multiple organ failure Surg Clin North Am 199575257-277
Goris RJ te Boekhorst TP Nuytinck JK Gimbrere JS Multiple-organ failure generalized autodestructive inflammation Arch Surg 19851201109-1115
Nuytinck HK Offermans XJ Kubat K Goris JA Whole-body inflammation in trauma patients an autopsy study Arch Surg 19881231519-1524
Examples that improve the prognosis of MOF include damage control surgery recognition of abdominal compartment syndrome lung protective ventilation
strategies and tight glucose level control
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal hypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
The Acute Respiratory Distress Syndrome Network Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome N Engl J Med 20003421301-1308
Amato MB Barbas CS Medeiros DM et al Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome N Engl J Med 1998338347-354
Van den Berghe G Wouters P Weekers F et al Intensive insulin therapy in the critically ill patients N Engl J Med 20013451359-1367
The incidence of postinjury MOF has been reported to be between 7 and 66 with an associated mortality rate between 31 and 80
Fry DE Pearlstein L Fulton RL Polk HC Jr Multiple system organ failure the role of uncontrolled infection Arch Surg 1980115136-140
Regel G Lobenhoffer P Grotz M Pape HC Lehmann U Tscherne H Treatment results of patients with multiple trauma an analysis of 3406 cases treated between 1972 and 1991 at a German level I trauma center J Trauma 19953870-78
Sauaia A Moore FA Moore EE Norris JM Lezotte DC Hamman RF Multiple organ failure can be predicted as early as 12 hours after injury J Trauma 199845291-303
Nast-Kolb D Aufmkolk M Rucholtz S Obertacke U Waydhas C Multiple organ failure still a major cause of morbidity but not mortality in blunt multiple trauma J Trauma 200151835-842 Durham RM Moran JJ Mazuski JE Shapiro MJ Baue AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
It has been suggested that MOF is disappearing owing to advances in trauma and critical care
Levine JH Durham RM Moran J Bauer A Multiple organ failure is it disappearing World J Surg 199620471-473
Recent reports have not demonstrated a consistent change in either the incidence or the mortality rate associated with postinjury MOF Some groups have reported no change in the incidence but a decreased mortality while others have reported both decreased incidence and mortality compared with historical control subjects
Durham RM Moran JJ Mazuski JE Shapiro MJ Bauer AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
Regel G Grotz M Weltner T Sturm JA Tscherne H Pattern of organ failure following severe trauma World J Surg 199620422-429
Orthopaedic Trauma
Open pelvic fractures in addition to the pelvic ring injury are associated with hemorrhage and neurological insult visceral injuries are more common and a high rate of infection is seen Mortality of open pelvic fractures historically approached 50 Control of bleeding is the most important initial measure followed by debridement and packing of open wounds
Open book- widened symphysis pubis Dislocated Rt SI joint Vallier + Jenkins In Trauma Anesthesia 2008
Type 1 fractures occur due to anterior-posterior
compressioncan cause the symphysis pubis to ldquopoprdquo open leading to pubic rami or ldquoopen
bookrdquo fractures A lateral compression fracture type 2 or vertical sheer facture (Type 3) can
also lead to severe bleeding Into the pelvis Pelvic and acetabular surgery are major surgical interventions
Figura 1- Aplicacioacuten de la engrapadora para la reseccioacuten pulmonar en cuntildea Los segmentos a resecar se limitan por medio de la aplicacioacuten de dispositivos de grapado orientados en direcciones perpendiculares tratando de mantener la mayor cantidad de tejido sano
Insercioacuten de engrapadora lineal cortante a traveacutes de los orificios del tracto de la herida pulmonar penetrante
Figura 3- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales con fuga aeacuterea visible
Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales
Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
- Slide 1
- Slide 2
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
- Slide 10
- Slide 11
- Slide 12
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- Slide 31
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Slide 36
- Slide 37
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
rFVIIaThe use of rFVIIa was associated with improved early and late survival after severe trauma and massive transfusion
rFVIIa was not associated with increased risk of thrombotic events
The Effect of Recombinant Activated Factor VII on Mortality in Combat-Related Casualties With Severe Trauma and Massive Transfusion
bull Philip C Spinella MD Jeremy G Perkins MD Daniel F McLaughlin MD Sarah E Niles MD MPHKurt W Grathwohl MD Alec C Beekley MD Jose Salinas PhD Sumeru Mehta MD Charles E Wade PhDand John B Holcomb MD J of Trauma- Feb 2008bull Dutton et al J Trauma 200457709 Conclusion consider early use of FVIIa in any pt with uncontrolled hemorrhage who has not responded to surgery or blood component therapy
bull Each unit of blood product biologically active + elevates risk of infections + ARDS (SDRA)Chaiwat et al Anesthesiology 2009110351 n=14070 pts NSCOT database retrospective
bull Older blood association whith elevates infection LOS MOSF + death Weinberg et al J Trauma 200865279
TemperatureA temperature lt 96degF or 35degC is associated with an increase in mortality (cardiac arrest SRP higher abnormal plaquelet function) Burch J Denton J Noble R Physiologic rationale for abbreviated laparotomy Surg Clin North Am 1997 77779-82 Trauma patients that are hypothermic are NOT PERFUSING their tissue
The COAGULATION CASCADE is an enzymatic pathway that degrades with temperature and ceases at 92 FGregory JS Francbeum L Towsened MC Incidence and timing of hypothermia in trauma patients undergoing operations J Trauma 1991 31795-800 If the temperature is lower than 33 C the mortality is 100although Beilman and col think itacutes a significant factor for MODS but not for the mortalityBeilman GJ Blondet JJ Early hypothermia in severely injured trauma patients is a significant risk factor for multiple organ dysfunction syndrome but not mortality Ann Surg 2009 May249(5)845-50
Diagnosis done
Damage Control Resuscitation
1 Hypotensive resuscitation
2 Hemostatic resuscitation
Damage control philosophy can be extended to haemostatic resuscitation
Restoring normal coagulation Minimizing crystalloidTraditional resuscitation strategies dilute the already deficient coagulation factors and increase multiple organ failure
The aggressive hemostatic resuscitation should be combined with equally aggressive control of bleeding
Spahn DR Cerny V Management of bleeding following major trauma a European guidelineCrit Care 2007 11(1) R 17
WAIT AND SEE
SURGEON
ABDOMINAL PACKING is a lifesaving technique for temporary control of severe injury and it is used in damage control surgery schedule
Its possible too applying packs in organ-specific techniques (early abdominal packing)
The median survival of the 70 certainly superior to the obtainable survival with immediate surgical repairbullIMMEDIATE FAILURES are substantially due to bleeding especially in underpacking caseREMOTE FAILURES septic and bound at the time of stay (above the 72 hours) and associated by the coexistence of lesions in these situations is possible a MOF syndrome due to excessive intra-abdominal pressure (overpacking) or to an Abdominal Compartment Syndrome
Stagnitti F Bresadola L Calderale SM Coletti M Ribaldi S Salvi PF Schillaci F Abdominal packing indications and method Ann Ital Chir 2003 Sep-Oct74(5)535-42
Benavides C Garciacutea C Apablaza S Rubilar P Ricaurte F Perales C et al Empaquetamiento hepaacutetico permanente con malla de poliglactina en estallido hepaacutetico secundario a Siacutendrome de Hellp Rev Chil Cir 2004 56 275-278 De la Fuente M Mendoza VH Robledo-Oyarzun F Cierre Temporal de la pared abdominal con polietileno Cir Ciruj 2002 70157-63 Serna VH El Siacutendrome Compartamental Abdominal Tesis de Postgrado Meacutexico 2000
When skin approximation is
not possible a temporary silo
is constructed by suturing a 3-
L cystoscopy irrigation bag
(BOGOTAacute BAG) to the skin
edge with a continuous No 2
nylon suture
The method of closure depends on whether skin approximation produces excessive intra-abdominal hypertension
Towel-clip closure of the skin is preferred because it is quick and easy
The second phase is intra-operative reassessment for hemorrhage control 30 minutes after initial abdominal closure in the operating room focusing on restoration of the patients physiological status specifically reversing hypothermia and coagulopathy
WE CAN HEAR THE HEMORRHAGE
The abdomen is then reopened and assessed for adequacy of hemostasis and for existence of residual mechanical bleeding This practice has allowed surgeons to minimize both early return to the operating room for ongoing hemorrhage and the amount of packing necessary for hemostasis With bleeding effectively controlled the abdomen is reclosed
The patient is transferred to the ICU for continued physiologic restoration in the third phase
Once coagulopathy hypothermia and acidosis have been corrected the patient can be returned to the operating room for definitive management of the injuries in the fourth phase
48-72 h after first surgery
COMPLICATIONS OF DAMAGE CONTROL LAPAROTOMY
1) ACS Acute Compartmental Syndrome
2) ARDS Acute Respiratory Distress of the Adult
3) MOF Multiple organ failure
4) DEATH
ABDOMINAL COMPARTMENT SYNDROME is defined as an intra-abdominal pressure of greater than 20 cm H2O with evidence of impaired organ function ie elevated peak airway pressures (gt45 cm
H2O) oliguria (lt05 mLkg per hour) or cardiovascular dysfunction
(hypotension despite adequate volume resuscitation or if a pulmonary artery catheter is present oxygen delivery index [calculated as milliliters of oxygen per minute per meter squared] of 600) Intra-abdominal pressure was measured indirectly using an indwelling Foley catheter as previously described
Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13 Damage control surgery in the abdomen an approach for the management of severe injured patientsGermanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis NNuffield Department of Surgery John Radcliffe Hospital Oxford UK Curr Opin Crit Care 2006 Aug12(4)346-50 Damage-control laparotomy Lee JC Peitzman AB Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA
ABDOMINAL COMPARTMENT SYNDROME occurred in 17 (33) of
52 Patients undergoing damage-control laparotomy and was
associated with a much higher incidence of ARDS and MOF (71 vs
31 without ACS P = 02)
More importantly our study suggests that primary fascial closure at
the termination of the initial damage-control laparotomy contributes to
the development of ACS as well as subsequent organ failure
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal ypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
Mayberry JC Mullins RJ Crass RA Trunkey DD Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure Arch Surg 1997132957-962
bull MOF Multiple organ failure
Seems to be a major source of postinjury morbidity and the leading cause of in-hospital mortality despite more than 25 years of intense investigation
Eiseman B Beart R Norton L Multiple organ failure Surg Gynecol Obstet 1977144323-326
Bauer AE Durham R Faist E Systemic inflammatory response syndrome (SIRS) multiple organ dysfunction syndrome (MODS) multiple organ failure (MOF) are we winning the battle Shock 19981079-89
The current pathophysiologic model of MOF focuses on uncontrolled systemic
hyperinflammation as a unifying concept following a variety of insults
Moore FA Moore EE Evolving concepts in the pathogenesis of postinjury multiple organ failure Surg Clin North Am 199575257-277
Goris RJ te Boekhorst TP Nuytinck JK Gimbrere JS Multiple-organ failure generalized autodestructive inflammation Arch Surg 19851201109-1115
Nuytinck HK Offermans XJ Kubat K Goris JA Whole-body inflammation in trauma patients an autopsy study Arch Surg 19881231519-1524
Examples that improve the prognosis of MOF include damage control surgery recognition of abdominal compartment syndrome lung protective ventilation
strategies and tight glucose level control
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal hypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
The Acute Respiratory Distress Syndrome Network Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome N Engl J Med 20003421301-1308
Amato MB Barbas CS Medeiros DM et al Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome N Engl J Med 1998338347-354
Van den Berghe G Wouters P Weekers F et al Intensive insulin therapy in the critically ill patients N Engl J Med 20013451359-1367
The incidence of postinjury MOF has been reported to be between 7 and 66 with an associated mortality rate between 31 and 80
Fry DE Pearlstein L Fulton RL Polk HC Jr Multiple system organ failure the role of uncontrolled infection Arch Surg 1980115136-140
Regel G Lobenhoffer P Grotz M Pape HC Lehmann U Tscherne H Treatment results of patients with multiple trauma an analysis of 3406 cases treated between 1972 and 1991 at a German level I trauma center J Trauma 19953870-78
Sauaia A Moore FA Moore EE Norris JM Lezotte DC Hamman RF Multiple organ failure can be predicted as early as 12 hours after injury J Trauma 199845291-303
Nast-Kolb D Aufmkolk M Rucholtz S Obertacke U Waydhas C Multiple organ failure still a major cause of morbidity but not mortality in blunt multiple trauma J Trauma 200151835-842 Durham RM Moran JJ Mazuski JE Shapiro MJ Baue AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
It has been suggested that MOF is disappearing owing to advances in trauma and critical care
Levine JH Durham RM Moran J Bauer A Multiple organ failure is it disappearing World J Surg 199620471-473
Recent reports have not demonstrated a consistent change in either the incidence or the mortality rate associated with postinjury MOF Some groups have reported no change in the incidence but a decreased mortality while others have reported both decreased incidence and mortality compared with historical control subjects
Durham RM Moran JJ Mazuski JE Shapiro MJ Bauer AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
Regel G Grotz M Weltner T Sturm JA Tscherne H Pattern of organ failure following severe trauma World J Surg 199620422-429
Orthopaedic Trauma
Open pelvic fractures in addition to the pelvic ring injury are associated with hemorrhage and neurological insult visceral injuries are more common and a high rate of infection is seen Mortality of open pelvic fractures historically approached 50 Control of bleeding is the most important initial measure followed by debridement and packing of open wounds
Open book- widened symphysis pubis Dislocated Rt SI joint Vallier + Jenkins In Trauma Anesthesia 2008
Type 1 fractures occur due to anterior-posterior
compressioncan cause the symphysis pubis to ldquopoprdquo open leading to pubic rami or ldquoopen
bookrdquo fractures A lateral compression fracture type 2 or vertical sheer facture (Type 3) can
also lead to severe bleeding Into the pelvis Pelvic and acetabular surgery are major surgical interventions
Figura 1- Aplicacioacuten de la engrapadora para la reseccioacuten pulmonar en cuntildea Los segmentos a resecar se limitan por medio de la aplicacioacuten de dispositivos de grapado orientados en direcciones perpendiculares tratando de mantener la mayor cantidad de tejido sano
Insercioacuten de engrapadora lineal cortante a traveacutes de los orificios del tracto de la herida pulmonar penetrante
Figura 3- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales con fuga aeacuterea visible
Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales
Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
- Slide 1
- Slide 2
- Slide 3
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- Slide 35
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- Slide 58
- Slide 59
-
bull Each unit of blood product biologically active + elevates risk of infections + ARDS (SDRA)Chaiwat et al Anesthesiology 2009110351 n=14070 pts NSCOT database retrospective
bull Older blood association whith elevates infection LOS MOSF + death Weinberg et al J Trauma 200865279
TemperatureA temperature lt 96degF or 35degC is associated with an increase in mortality (cardiac arrest SRP higher abnormal plaquelet function) Burch J Denton J Noble R Physiologic rationale for abbreviated laparotomy Surg Clin North Am 1997 77779-82 Trauma patients that are hypothermic are NOT PERFUSING their tissue
The COAGULATION CASCADE is an enzymatic pathway that degrades with temperature and ceases at 92 FGregory JS Francbeum L Towsened MC Incidence and timing of hypothermia in trauma patients undergoing operations J Trauma 1991 31795-800 If the temperature is lower than 33 C the mortality is 100although Beilman and col think itacutes a significant factor for MODS but not for the mortalityBeilman GJ Blondet JJ Early hypothermia in severely injured trauma patients is a significant risk factor for multiple organ dysfunction syndrome but not mortality Ann Surg 2009 May249(5)845-50
Diagnosis done
Damage Control Resuscitation
1 Hypotensive resuscitation
2 Hemostatic resuscitation
Damage control philosophy can be extended to haemostatic resuscitation
Restoring normal coagulation Minimizing crystalloidTraditional resuscitation strategies dilute the already deficient coagulation factors and increase multiple organ failure
The aggressive hemostatic resuscitation should be combined with equally aggressive control of bleeding
Spahn DR Cerny V Management of bleeding following major trauma a European guidelineCrit Care 2007 11(1) R 17
WAIT AND SEE
SURGEON
ABDOMINAL PACKING is a lifesaving technique for temporary control of severe injury and it is used in damage control surgery schedule
Its possible too applying packs in organ-specific techniques (early abdominal packing)
The median survival of the 70 certainly superior to the obtainable survival with immediate surgical repairbullIMMEDIATE FAILURES are substantially due to bleeding especially in underpacking caseREMOTE FAILURES septic and bound at the time of stay (above the 72 hours) and associated by the coexistence of lesions in these situations is possible a MOF syndrome due to excessive intra-abdominal pressure (overpacking) or to an Abdominal Compartment Syndrome
Stagnitti F Bresadola L Calderale SM Coletti M Ribaldi S Salvi PF Schillaci F Abdominal packing indications and method Ann Ital Chir 2003 Sep-Oct74(5)535-42
Benavides C Garciacutea C Apablaza S Rubilar P Ricaurte F Perales C et al Empaquetamiento hepaacutetico permanente con malla de poliglactina en estallido hepaacutetico secundario a Siacutendrome de Hellp Rev Chil Cir 2004 56 275-278 De la Fuente M Mendoza VH Robledo-Oyarzun F Cierre Temporal de la pared abdominal con polietileno Cir Ciruj 2002 70157-63 Serna VH El Siacutendrome Compartamental Abdominal Tesis de Postgrado Meacutexico 2000
When skin approximation is
not possible a temporary silo
is constructed by suturing a 3-
L cystoscopy irrigation bag
(BOGOTAacute BAG) to the skin
edge with a continuous No 2
nylon suture
The method of closure depends on whether skin approximation produces excessive intra-abdominal hypertension
Towel-clip closure of the skin is preferred because it is quick and easy
The second phase is intra-operative reassessment for hemorrhage control 30 minutes after initial abdominal closure in the operating room focusing on restoration of the patients physiological status specifically reversing hypothermia and coagulopathy
WE CAN HEAR THE HEMORRHAGE
The abdomen is then reopened and assessed for adequacy of hemostasis and for existence of residual mechanical bleeding This practice has allowed surgeons to minimize both early return to the operating room for ongoing hemorrhage and the amount of packing necessary for hemostasis With bleeding effectively controlled the abdomen is reclosed
The patient is transferred to the ICU for continued physiologic restoration in the third phase
Once coagulopathy hypothermia and acidosis have been corrected the patient can be returned to the operating room for definitive management of the injuries in the fourth phase
48-72 h after first surgery
COMPLICATIONS OF DAMAGE CONTROL LAPAROTOMY
1) ACS Acute Compartmental Syndrome
2) ARDS Acute Respiratory Distress of the Adult
3) MOF Multiple organ failure
4) DEATH
ABDOMINAL COMPARTMENT SYNDROME is defined as an intra-abdominal pressure of greater than 20 cm H2O with evidence of impaired organ function ie elevated peak airway pressures (gt45 cm
H2O) oliguria (lt05 mLkg per hour) or cardiovascular dysfunction
(hypotension despite adequate volume resuscitation or if a pulmonary artery catheter is present oxygen delivery index [calculated as milliliters of oxygen per minute per meter squared] of 600) Intra-abdominal pressure was measured indirectly using an indwelling Foley catheter as previously described
Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13 Damage control surgery in the abdomen an approach for the management of severe injured patientsGermanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis NNuffield Department of Surgery John Radcliffe Hospital Oxford UK Curr Opin Crit Care 2006 Aug12(4)346-50 Damage-control laparotomy Lee JC Peitzman AB Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA
ABDOMINAL COMPARTMENT SYNDROME occurred in 17 (33) of
52 Patients undergoing damage-control laparotomy and was
associated with a much higher incidence of ARDS and MOF (71 vs
31 without ACS P = 02)
More importantly our study suggests that primary fascial closure at
the termination of the initial damage-control laparotomy contributes to
the development of ACS as well as subsequent organ failure
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal ypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
Mayberry JC Mullins RJ Crass RA Trunkey DD Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure Arch Surg 1997132957-962
bull MOF Multiple organ failure
Seems to be a major source of postinjury morbidity and the leading cause of in-hospital mortality despite more than 25 years of intense investigation
Eiseman B Beart R Norton L Multiple organ failure Surg Gynecol Obstet 1977144323-326
Bauer AE Durham R Faist E Systemic inflammatory response syndrome (SIRS) multiple organ dysfunction syndrome (MODS) multiple organ failure (MOF) are we winning the battle Shock 19981079-89
The current pathophysiologic model of MOF focuses on uncontrolled systemic
hyperinflammation as a unifying concept following a variety of insults
Moore FA Moore EE Evolving concepts in the pathogenesis of postinjury multiple organ failure Surg Clin North Am 199575257-277
Goris RJ te Boekhorst TP Nuytinck JK Gimbrere JS Multiple-organ failure generalized autodestructive inflammation Arch Surg 19851201109-1115
Nuytinck HK Offermans XJ Kubat K Goris JA Whole-body inflammation in trauma patients an autopsy study Arch Surg 19881231519-1524
Examples that improve the prognosis of MOF include damage control surgery recognition of abdominal compartment syndrome lung protective ventilation
strategies and tight glucose level control
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal hypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
The Acute Respiratory Distress Syndrome Network Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome N Engl J Med 20003421301-1308
Amato MB Barbas CS Medeiros DM et al Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome N Engl J Med 1998338347-354
Van den Berghe G Wouters P Weekers F et al Intensive insulin therapy in the critically ill patients N Engl J Med 20013451359-1367
The incidence of postinjury MOF has been reported to be between 7 and 66 with an associated mortality rate between 31 and 80
Fry DE Pearlstein L Fulton RL Polk HC Jr Multiple system organ failure the role of uncontrolled infection Arch Surg 1980115136-140
Regel G Lobenhoffer P Grotz M Pape HC Lehmann U Tscherne H Treatment results of patients with multiple trauma an analysis of 3406 cases treated between 1972 and 1991 at a German level I trauma center J Trauma 19953870-78
Sauaia A Moore FA Moore EE Norris JM Lezotte DC Hamman RF Multiple organ failure can be predicted as early as 12 hours after injury J Trauma 199845291-303
Nast-Kolb D Aufmkolk M Rucholtz S Obertacke U Waydhas C Multiple organ failure still a major cause of morbidity but not mortality in blunt multiple trauma J Trauma 200151835-842 Durham RM Moran JJ Mazuski JE Shapiro MJ Baue AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
It has been suggested that MOF is disappearing owing to advances in trauma and critical care
Levine JH Durham RM Moran J Bauer A Multiple organ failure is it disappearing World J Surg 199620471-473
Recent reports have not demonstrated a consistent change in either the incidence or the mortality rate associated with postinjury MOF Some groups have reported no change in the incidence but a decreased mortality while others have reported both decreased incidence and mortality compared with historical control subjects
Durham RM Moran JJ Mazuski JE Shapiro MJ Bauer AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
Regel G Grotz M Weltner T Sturm JA Tscherne H Pattern of organ failure following severe trauma World J Surg 199620422-429
Orthopaedic Trauma
Open pelvic fractures in addition to the pelvic ring injury are associated with hemorrhage and neurological insult visceral injuries are more common and a high rate of infection is seen Mortality of open pelvic fractures historically approached 50 Control of bleeding is the most important initial measure followed by debridement and packing of open wounds
Open book- widened symphysis pubis Dislocated Rt SI joint Vallier + Jenkins In Trauma Anesthesia 2008
Type 1 fractures occur due to anterior-posterior
compressioncan cause the symphysis pubis to ldquopoprdquo open leading to pubic rami or ldquoopen
bookrdquo fractures A lateral compression fracture type 2 or vertical sheer facture (Type 3) can
also lead to severe bleeding Into the pelvis Pelvic and acetabular surgery are major surgical interventions
Figura 1- Aplicacioacuten de la engrapadora para la reseccioacuten pulmonar en cuntildea Los segmentos a resecar se limitan por medio de la aplicacioacuten de dispositivos de grapado orientados en direcciones perpendiculares tratando de mantener la mayor cantidad de tejido sano
Insercioacuten de engrapadora lineal cortante a traveacutes de los orificios del tracto de la herida pulmonar penetrante
Figura 3- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales con fuga aeacuterea visible
Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales
Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
- Slide 1
- Slide 2
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
- Slide 10
- Slide 11
- Slide 12
- Slide 13
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- Slide 31
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- Slide 33
- Slide 34
- Slide 35
- Slide 36
- Slide 37
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
TemperatureA temperature lt 96degF or 35degC is associated with an increase in mortality (cardiac arrest SRP higher abnormal plaquelet function) Burch J Denton J Noble R Physiologic rationale for abbreviated laparotomy Surg Clin North Am 1997 77779-82 Trauma patients that are hypothermic are NOT PERFUSING their tissue
The COAGULATION CASCADE is an enzymatic pathway that degrades with temperature and ceases at 92 FGregory JS Francbeum L Towsened MC Incidence and timing of hypothermia in trauma patients undergoing operations J Trauma 1991 31795-800 If the temperature is lower than 33 C the mortality is 100although Beilman and col think itacutes a significant factor for MODS but not for the mortalityBeilman GJ Blondet JJ Early hypothermia in severely injured trauma patients is a significant risk factor for multiple organ dysfunction syndrome but not mortality Ann Surg 2009 May249(5)845-50
Diagnosis done
Damage Control Resuscitation
1 Hypotensive resuscitation
2 Hemostatic resuscitation
Damage control philosophy can be extended to haemostatic resuscitation
Restoring normal coagulation Minimizing crystalloidTraditional resuscitation strategies dilute the already deficient coagulation factors and increase multiple organ failure
The aggressive hemostatic resuscitation should be combined with equally aggressive control of bleeding
Spahn DR Cerny V Management of bleeding following major trauma a European guidelineCrit Care 2007 11(1) R 17
WAIT AND SEE
SURGEON
ABDOMINAL PACKING is a lifesaving technique for temporary control of severe injury and it is used in damage control surgery schedule
Its possible too applying packs in organ-specific techniques (early abdominal packing)
The median survival of the 70 certainly superior to the obtainable survival with immediate surgical repairbullIMMEDIATE FAILURES are substantially due to bleeding especially in underpacking caseREMOTE FAILURES septic and bound at the time of stay (above the 72 hours) and associated by the coexistence of lesions in these situations is possible a MOF syndrome due to excessive intra-abdominal pressure (overpacking) or to an Abdominal Compartment Syndrome
Stagnitti F Bresadola L Calderale SM Coletti M Ribaldi S Salvi PF Schillaci F Abdominal packing indications and method Ann Ital Chir 2003 Sep-Oct74(5)535-42
Benavides C Garciacutea C Apablaza S Rubilar P Ricaurte F Perales C et al Empaquetamiento hepaacutetico permanente con malla de poliglactina en estallido hepaacutetico secundario a Siacutendrome de Hellp Rev Chil Cir 2004 56 275-278 De la Fuente M Mendoza VH Robledo-Oyarzun F Cierre Temporal de la pared abdominal con polietileno Cir Ciruj 2002 70157-63 Serna VH El Siacutendrome Compartamental Abdominal Tesis de Postgrado Meacutexico 2000
When skin approximation is
not possible a temporary silo
is constructed by suturing a 3-
L cystoscopy irrigation bag
(BOGOTAacute BAG) to the skin
edge with a continuous No 2
nylon suture
The method of closure depends on whether skin approximation produces excessive intra-abdominal hypertension
Towel-clip closure of the skin is preferred because it is quick and easy
The second phase is intra-operative reassessment for hemorrhage control 30 minutes after initial abdominal closure in the operating room focusing on restoration of the patients physiological status specifically reversing hypothermia and coagulopathy
WE CAN HEAR THE HEMORRHAGE
The abdomen is then reopened and assessed for adequacy of hemostasis and for existence of residual mechanical bleeding This practice has allowed surgeons to minimize both early return to the operating room for ongoing hemorrhage and the amount of packing necessary for hemostasis With bleeding effectively controlled the abdomen is reclosed
The patient is transferred to the ICU for continued physiologic restoration in the third phase
Once coagulopathy hypothermia and acidosis have been corrected the patient can be returned to the operating room for definitive management of the injuries in the fourth phase
48-72 h after first surgery
COMPLICATIONS OF DAMAGE CONTROL LAPAROTOMY
1) ACS Acute Compartmental Syndrome
2) ARDS Acute Respiratory Distress of the Adult
3) MOF Multiple organ failure
4) DEATH
ABDOMINAL COMPARTMENT SYNDROME is defined as an intra-abdominal pressure of greater than 20 cm H2O with evidence of impaired organ function ie elevated peak airway pressures (gt45 cm
H2O) oliguria (lt05 mLkg per hour) or cardiovascular dysfunction
(hypotension despite adequate volume resuscitation or if a pulmonary artery catheter is present oxygen delivery index [calculated as milliliters of oxygen per minute per meter squared] of 600) Intra-abdominal pressure was measured indirectly using an indwelling Foley catheter as previously described
Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13 Damage control surgery in the abdomen an approach for the management of severe injured patientsGermanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis NNuffield Department of Surgery John Radcliffe Hospital Oxford UK Curr Opin Crit Care 2006 Aug12(4)346-50 Damage-control laparotomy Lee JC Peitzman AB Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA
ABDOMINAL COMPARTMENT SYNDROME occurred in 17 (33) of
52 Patients undergoing damage-control laparotomy and was
associated with a much higher incidence of ARDS and MOF (71 vs
31 without ACS P = 02)
More importantly our study suggests that primary fascial closure at
the termination of the initial damage-control laparotomy contributes to
the development of ACS as well as subsequent organ failure
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal ypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
Mayberry JC Mullins RJ Crass RA Trunkey DD Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure Arch Surg 1997132957-962
bull MOF Multiple organ failure
Seems to be a major source of postinjury morbidity and the leading cause of in-hospital mortality despite more than 25 years of intense investigation
Eiseman B Beart R Norton L Multiple organ failure Surg Gynecol Obstet 1977144323-326
Bauer AE Durham R Faist E Systemic inflammatory response syndrome (SIRS) multiple organ dysfunction syndrome (MODS) multiple organ failure (MOF) are we winning the battle Shock 19981079-89
The current pathophysiologic model of MOF focuses on uncontrolled systemic
hyperinflammation as a unifying concept following a variety of insults
Moore FA Moore EE Evolving concepts in the pathogenesis of postinjury multiple organ failure Surg Clin North Am 199575257-277
Goris RJ te Boekhorst TP Nuytinck JK Gimbrere JS Multiple-organ failure generalized autodestructive inflammation Arch Surg 19851201109-1115
Nuytinck HK Offermans XJ Kubat K Goris JA Whole-body inflammation in trauma patients an autopsy study Arch Surg 19881231519-1524
Examples that improve the prognosis of MOF include damage control surgery recognition of abdominal compartment syndrome lung protective ventilation
strategies and tight glucose level control
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal hypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
The Acute Respiratory Distress Syndrome Network Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome N Engl J Med 20003421301-1308
Amato MB Barbas CS Medeiros DM et al Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome N Engl J Med 1998338347-354
Van den Berghe G Wouters P Weekers F et al Intensive insulin therapy in the critically ill patients N Engl J Med 20013451359-1367
The incidence of postinjury MOF has been reported to be between 7 and 66 with an associated mortality rate between 31 and 80
Fry DE Pearlstein L Fulton RL Polk HC Jr Multiple system organ failure the role of uncontrolled infection Arch Surg 1980115136-140
Regel G Lobenhoffer P Grotz M Pape HC Lehmann U Tscherne H Treatment results of patients with multiple trauma an analysis of 3406 cases treated between 1972 and 1991 at a German level I trauma center J Trauma 19953870-78
Sauaia A Moore FA Moore EE Norris JM Lezotte DC Hamman RF Multiple organ failure can be predicted as early as 12 hours after injury J Trauma 199845291-303
Nast-Kolb D Aufmkolk M Rucholtz S Obertacke U Waydhas C Multiple organ failure still a major cause of morbidity but not mortality in blunt multiple trauma J Trauma 200151835-842 Durham RM Moran JJ Mazuski JE Shapiro MJ Baue AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
It has been suggested that MOF is disappearing owing to advances in trauma and critical care
Levine JH Durham RM Moran J Bauer A Multiple organ failure is it disappearing World J Surg 199620471-473
Recent reports have not demonstrated a consistent change in either the incidence or the mortality rate associated with postinjury MOF Some groups have reported no change in the incidence but a decreased mortality while others have reported both decreased incidence and mortality compared with historical control subjects
Durham RM Moran JJ Mazuski JE Shapiro MJ Bauer AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
Regel G Grotz M Weltner T Sturm JA Tscherne H Pattern of organ failure following severe trauma World J Surg 199620422-429
Orthopaedic Trauma
Open pelvic fractures in addition to the pelvic ring injury are associated with hemorrhage and neurological insult visceral injuries are more common and a high rate of infection is seen Mortality of open pelvic fractures historically approached 50 Control of bleeding is the most important initial measure followed by debridement and packing of open wounds
Open book- widened symphysis pubis Dislocated Rt SI joint Vallier + Jenkins In Trauma Anesthesia 2008
Type 1 fractures occur due to anterior-posterior
compressioncan cause the symphysis pubis to ldquopoprdquo open leading to pubic rami or ldquoopen
bookrdquo fractures A lateral compression fracture type 2 or vertical sheer facture (Type 3) can
also lead to severe bleeding Into the pelvis Pelvic and acetabular surgery are major surgical interventions
Figura 1- Aplicacioacuten de la engrapadora para la reseccioacuten pulmonar en cuntildea Los segmentos a resecar se limitan por medio de la aplicacioacuten de dispositivos de grapado orientados en direcciones perpendiculares tratando de mantener la mayor cantidad de tejido sano
Insercioacuten de engrapadora lineal cortante a traveacutes de los orificios del tracto de la herida pulmonar penetrante
Figura 3- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales con fuga aeacuterea visible
Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales
Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
- Slide 1
- Slide 2
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
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- Slide 35
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- Slide 38
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- Slide 41
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- Slide 57
- Slide 58
- Slide 59
-
Diagnosis done
Damage Control Resuscitation
1 Hypotensive resuscitation
2 Hemostatic resuscitation
Damage control philosophy can be extended to haemostatic resuscitation
Restoring normal coagulation Minimizing crystalloidTraditional resuscitation strategies dilute the already deficient coagulation factors and increase multiple organ failure
The aggressive hemostatic resuscitation should be combined with equally aggressive control of bleeding
Spahn DR Cerny V Management of bleeding following major trauma a European guidelineCrit Care 2007 11(1) R 17
WAIT AND SEE
SURGEON
ABDOMINAL PACKING is a lifesaving technique for temporary control of severe injury and it is used in damage control surgery schedule
Its possible too applying packs in organ-specific techniques (early abdominal packing)
The median survival of the 70 certainly superior to the obtainable survival with immediate surgical repairbullIMMEDIATE FAILURES are substantially due to bleeding especially in underpacking caseREMOTE FAILURES septic and bound at the time of stay (above the 72 hours) and associated by the coexistence of lesions in these situations is possible a MOF syndrome due to excessive intra-abdominal pressure (overpacking) or to an Abdominal Compartment Syndrome
Stagnitti F Bresadola L Calderale SM Coletti M Ribaldi S Salvi PF Schillaci F Abdominal packing indications and method Ann Ital Chir 2003 Sep-Oct74(5)535-42
Benavides C Garciacutea C Apablaza S Rubilar P Ricaurte F Perales C et al Empaquetamiento hepaacutetico permanente con malla de poliglactina en estallido hepaacutetico secundario a Siacutendrome de Hellp Rev Chil Cir 2004 56 275-278 De la Fuente M Mendoza VH Robledo-Oyarzun F Cierre Temporal de la pared abdominal con polietileno Cir Ciruj 2002 70157-63 Serna VH El Siacutendrome Compartamental Abdominal Tesis de Postgrado Meacutexico 2000
When skin approximation is
not possible a temporary silo
is constructed by suturing a 3-
L cystoscopy irrigation bag
(BOGOTAacute BAG) to the skin
edge with a continuous No 2
nylon suture
The method of closure depends on whether skin approximation produces excessive intra-abdominal hypertension
Towel-clip closure of the skin is preferred because it is quick and easy
The second phase is intra-operative reassessment for hemorrhage control 30 minutes after initial abdominal closure in the operating room focusing on restoration of the patients physiological status specifically reversing hypothermia and coagulopathy
WE CAN HEAR THE HEMORRHAGE
The abdomen is then reopened and assessed for adequacy of hemostasis and for existence of residual mechanical bleeding This practice has allowed surgeons to minimize both early return to the operating room for ongoing hemorrhage and the amount of packing necessary for hemostasis With bleeding effectively controlled the abdomen is reclosed
The patient is transferred to the ICU for continued physiologic restoration in the third phase
Once coagulopathy hypothermia and acidosis have been corrected the patient can be returned to the operating room for definitive management of the injuries in the fourth phase
48-72 h after first surgery
COMPLICATIONS OF DAMAGE CONTROL LAPAROTOMY
1) ACS Acute Compartmental Syndrome
2) ARDS Acute Respiratory Distress of the Adult
3) MOF Multiple organ failure
4) DEATH
ABDOMINAL COMPARTMENT SYNDROME is defined as an intra-abdominal pressure of greater than 20 cm H2O with evidence of impaired organ function ie elevated peak airway pressures (gt45 cm
H2O) oliguria (lt05 mLkg per hour) or cardiovascular dysfunction
(hypotension despite adequate volume resuscitation or if a pulmonary artery catheter is present oxygen delivery index [calculated as milliliters of oxygen per minute per meter squared] of 600) Intra-abdominal pressure was measured indirectly using an indwelling Foley catheter as previously described
Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13 Damage control surgery in the abdomen an approach for the management of severe injured patientsGermanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis NNuffield Department of Surgery John Radcliffe Hospital Oxford UK Curr Opin Crit Care 2006 Aug12(4)346-50 Damage-control laparotomy Lee JC Peitzman AB Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA
ABDOMINAL COMPARTMENT SYNDROME occurred in 17 (33) of
52 Patients undergoing damage-control laparotomy and was
associated with a much higher incidence of ARDS and MOF (71 vs
31 without ACS P = 02)
More importantly our study suggests that primary fascial closure at
the termination of the initial damage-control laparotomy contributes to
the development of ACS as well as subsequent organ failure
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal ypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
Mayberry JC Mullins RJ Crass RA Trunkey DD Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure Arch Surg 1997132957-962
bull MOF Multiple organ failure
Seems to be a major source of postinjury morbidity and the leading cause of in-hospital mortality despite more than 25 years of intense investigation
Eiseman B Beart R Norton L Multiple organ failure Surg Gynecol Obstet 1977144323-326
Bauer AE Durham R Faist E Systemic inflammatory response syndrome (SIRS) multiple organ dysfunction syndrome (MODS) multiple organ failure (MOF) are we winning the battle Shock 19981079-89
The current pathophysiologic model of MOF focuses on uncontrolled systemic
hyperinflammation as a unifying concept following a variety of insults
Moore FA Moore EE Evolving concepts in the pathogenesis of postinjury multiple organ failure Surg Clin North Am 199575257-277
Goris RJ te Boekhorst TP Nuytinck JK Gimbrere JS Multiple-organ failure generalized autodestructive inflammation Arch Surg 19851201109-1115
Nuytinck HK Offermans XJ Kubat K Goris JA Whole-body inflammation in trauma patients an autopsy study Arch Surg 19881231519-1524
Examples that improve the prognosis of MOF include damage control surgery recognition of abdominal compartment syndrome lung protective ventilation
strategies and tight glucose level control
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal hypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
The Acute Respiratory Distress Syndrome Network Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome N Engl J Med 20003421301-1308
Amato MB Barbas CS Medeiros DM et al Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome N Engl J Med 1998338347-354
Van den Berghe G Wouters P Weekers F et al Intensive insulin therapy in the critically ill patients N Engl J Med 20013451359-1367
The incidence of postinjury MOF has been reported to be between 7 and 66 with an associated mortality rate between 31 and 80
Fry DE Pearlstein L Fulton RL Polk HC Jr Multiple system organ failure the role of uncontrolled infection Arch Surg 1980115136-140
Regel G Lobenhoffer P Grotz M Pape HC Lehmann U Tscherne H Treatment results of patients with multiple trauma an analysis of 3406 cases treated between 1972 and 1991 at a German level I trauma center J Trauma 19953870-78
Sauaia A Moore FA Moore EE Norris JM Lezotte DC Hamman RF Multiple organ failure can be predicted as early as 12 hours after injury J Trauma 199845291-303
Nast-Kolb D Aufmkolk M Rucholtz S Obertacke U Waydhas C Multiple organ failure still a major cause of morbidity but not mortality in blunt multiple trauma J Trauma 200151835-842 Durham RM Moran JJ Mazuski JE Shapiro MJ Baue AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
It has been suggested that MOF is disappearing owing to advances in trauma and critical care
Levine JH Durham RM Moran J Bauer A Multiple organ failure is it disappearing World J Surg 199620471-473
Recent reports have not demonstrated a consistent change in either the incidence or the mortality rate associated with postinjury MOF Some groups have reported no change in the incidence but a decreased mortality while others have reported both decreased incidence and mortality compared with historical control subjects
Durham RM Moran JJ Mazuski JE Shapiro MJ Bauer AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
Regel G Grotz M Weltner T Sturm JA Tscherne H Pattern of organ failure following severe trauma World J Surg 199620422-429
Orthopaedic Trauma
Open pelvic fractures in addition to the pelvic ring injury are associated with hemorrhage and neurological insult visceral injuries are more common and a high rate of infection is seen Mortality of open pelvic fractures historically approached 50 Control of bleeding is the most important initial measure followed by debridement and packing of open wounds
Open book- widened symphysis pubis Dislocated Rt SI joint Vallier + Jenkins In Trauma Anesthesia 2008
Type 1 fractures occur due to anterior-posterior
compressioncan cause the symphysis pubis to ldquopoprdquo open leading to pubic rami or ldquoopen
bookrdquo fractures A lateral compression fracture type 2 or vertical sheer facture (Type 3) can
also lead to severe bleeding Into the pelvis Pelvic and acetabular surgery are major surgical interventions
Figura 1- Aplicacioacuten de la engrapadora para la reseccioacuten pulmonar en cuntildea Los segmentos a resecar se limitan por medio de la aplicacioacuten de dispositivos de grapado orientados en direcciones perpendiculares tratando de mantener la mayor cantidad de tejido sano
Insercioacuten de engrapadora lineal cortante a traveacutes de los orificios del tracto de la herida pulmonar penetrante
Figura 3- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales con fuga aeacuterea visible
Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales
Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
- Slide 1
- Slide 2
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
- Slide 10
- Slide 11
- Slide 12
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- Slide 31
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Slide 36
- Slide 37
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
Damage control philosophy can be extended to haemostatic resuscitation
Restoring normal coagulation Minimizing crystalloidTraditional resuscitation strategies dilute the already deficient coagulation factors and increase multiple organ failure
The aggressive hemostatic resuscitation should be combined with equally aggressive control of bleeding
Spahn DR Cerny V Management of bleeding following major trauma a European guidelineCrit Care 2007 11(1) R 17
WAIT AND SEE
SURGEON
ABDOMINAL PACKING is a lifesaving technique for temporary control of severe injury and it is used in damage control surgery schedule
Its possible too applying packs in organ-specific techniques (early abdominal packing)
The median survival of the 70 certainly superior to the obtainable survival with immediate surgical repairbullIMMEDIATE FAILURES are substantially due to bleeding especially in underpacking caseREMOTE FAILURES septic and bound at the time of stay (above the 72 hours) and associated by the coexistence of lesions in these situations is possible a MOF syndrome due to excessive intra-abdominal pressure (overpacking) or to an Abdominal Compartment Syndrome
Stagnitti F Bresadola L Calderale SM Coletti M Ribaldi S Salvi PF Schillaci F Abdominal packing indications and method Ann Ital Chir 2003 Sep-Oct74(5)535-42
Benavides C Garciacutea C Apablaza S Rubilar P Ricaurte F Perales C et al Empaquetamiento hepaacutetico permanente con malla de poliglactina en estallido hepaacutetico secundario a Siacutendrome de Hellp Rev Chil Cir 2004 56 275-278 De la Fuente M Mendoza VH Robledo-Oyarzun F Cierre Temporal de la pared abdominal con polietileno Cir Ciruj 2002 70157-63 Serna VH El Siacutendrome Compartamental Abdominal Tesis de Postgrado Meacutexico 2000
When skin approximation is
not possible a temporary silo
is constructed by suturing a 3-
L cystoscopy irrigation bag
(BOGOTAacute BAG) to the skin
edge with a continuous No 2
nylon suture
The method of closure depends on whether skin approximation produces excessive intra-abdominal hypertension
Towel-clip closure of the skin is preferred because it is quick and easy
The second phase is intra-operative reassessment for hemorrhage control 30 minutes after initial abdominal closure in the operating room focusing on restoration of the patients physiological status specifically reversing hypothermia and coagulopathy
WE CAN HEAR THE HEMORRHAGE
The abdomen is then reopened and assessed for adequacy of hemostasis and for existence of residual mechanical bleeding This practice has allowed surgeons to minimize both early return to the operating room for ongoing hemorrhage and the amount of packing necessary for hemostasis With bleeding effectively controlled the abdomen is reclosed
The patient is transferred to the ICU for continued physiologic restoration in the third phase
Once coagulopathy hypothermia and acidosis have been corrected the patient can be returned to the operating room for definitive management of the injuries in the fourth phase
48-72 h after first surgery
COMPLICATIONS OF DAMAGE CONTROL LAPAROTOMY
1) ACS Acute Compartmental Syndrome
2) ARDS Acute Respiratory Distress of the Adult
3) MOF Multiple organ failure
4) DEATH
ABDOMINAL COMPARTMENT SYNDROME is defined as an intra-abdominal pressure of greater than 20 cm H2O with evidence of impaired organ function ie elevated peak airway pressures (gt45 cm
H2O) oliguria (lt05 mLkg per hour) or cardiovascular dysfunction
(hypotension despite adequate volume resuscitation or if a pulmonary artery catheter is present oxygen delivery index [calculated as milliliters of oxygen per minute per meter squared] of 600) Intra-abdominal pressure was measured indirectly using an indwelling Foley catheter as previously described
Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13 Damage control surgery in the abdomen an approach for the management of severe injured patientsGermanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis NNuffield Department of Surgery John Radcliffe Hospital Oxford UK Curr Opin Crit Care 2006 Aug12(4)346-50 Damage-control laparotomy Lee JC Peitzman AB Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA
ABDOMINAL COMPARTMENT SYNDROME occurred in 17 (33) of
52 Patients undergoing damage-control laparotomy and was
associated with a much higher incidence of ARDS and MOF (71 vs
31 without ACS P = 02)
More importantly our study suggests that primary fascial closure at
the termination of the initial damage-control laparotomy contributes to
the development of ACS as well as subsequent organ failure
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal ypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
Mayberry JC Mullins RJ Crass RA Trunkey DD Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure Arch Surg 1997132957-962
bull MOF Multiple organ failure
Seems to be a major source of postinjury morbidity and the leading cause of in-hospital mortality despite more than 25 years of intense investigation
Eiseman B Beart R Norton L Multiple organ failure Surg Gynecol Obstet 1977144323-326
Bauer AE Durham R Faist E Systemic inflammatory response syndrome (SIRS) multiple organ dysfunction syndrome (MODS) multiple organ failure (MOF) are we winning the battle Shock 19981079-89
The current pathophysiologic model of MOF focuses on uncontrolled systemic
hyperinflammation as a unifying concept following a variety of insults
Moore FA Moore EE Evolving concepts in the pathogenesis of postinjury multiple organ failure Surg Clin North Am 199575257-277
Goris RJ te Boekhorst TP Nuytinck JK Gimbrere JS Multiple-organ failure generalized autodestructive inflammation Arch Surg 19851201109-1115
Nuytinck HK Offermans XJ Kubat K Goris JA Whole-body inflammation in trauma patients an autopsy study Arch Surg 19881231519-1524
Examples that improve the prognosis of MOF include damage control surgery recognition of abdominal compartment syndrome lung protective ventilation
strategies and tight glucose level control
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal hypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
The Acute Respiratory Distress Syndrome Network Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome N Engl J Med 20003421301-1308
Amato MB Barbas CS Medeiros DM et al Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome N Engl J Med 1998338347-354
Van den Berghe G Wouters P Weekers F et al Intensive insulin therapy in the critically ill patients N Engl J Med 20013451359-1367
The incidence of postinjury MOF has been reported to be between 7 and 66 with an associated mortality rate between 31 and 80
Fry DE Pearlstein L Fulton RL Polk HC Jr Multiple system organ failure the role of uncontrolled infection Arch Surg 1980115136-140
Regel G Lobenhoffer P Grotz M Pape HC Lehmann U Tscherne H Treatment results of patients with multiple trauma an analysis of 3406 cases treated between 1972 and 1991 at a German level I trauma center J Trauma 19953870-78
Sauaia A Moore FA Moore EE Norris JM Lezotte DC Hamman RF Multiple organ failure can be predicted as early as 12 hours after injury J Trauma 199845291-303
Nast-Kolb D Aufmkolk M Rucholtz S Obertacke U Waydhas C Multiple organ failure still a major cause of morbidity but not mortality in blunt multiple trauma J Trauma 200151835-842 Durham RM Moran JJ Mazuski JE Shapiro MJ Baue AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
It has been suggested that MOF is disappearing owing to advances in trauma and critical care
Levine JH Durham RM Moran J Bauer A Multiple organ failure is it disappearing World J Surg 199620471-473
Recent reports have not demonstrated a consistent change in either the incidence or the mortality rate associated with postinjury MOF Some groups have reported no change in the incidence but a decreased mortality while others have reported both decreased incidence and mortality compared with historical control subjects
Durham RM Moran JJ Mazuski JE Shapiro MJ Bauer AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
Regel G Grotz M Weltner T Sturm JA Tscherne H Pattern of organ failure following severe trauma World J Surg 199620422-429
Orthopaedic Trauma
Open pelvic fractures in addition to the pelvic ring injury are associated with hemorrhage and neurological insult visceral injuries are more common and a high rate of infection is seen Mortality of open pelvic fractures historically approached 50 Control of bleeding is the most important initial measure followed by debridement and packing of open wounds
Open book- widened symphysis pubis Dislocated Rt SI joint Vallier + Jenkins In Trauma Anesthesia 2008
Type 1 fractures occur due to anterior-posterior
compressioncan cause the symphysis pubis to ldquopoprdquo open leading to pubic rami or ldquoopen
bookrdquo fractures A lateral compression fracture type 2 or vertical sheer facture (Type 3) can
also lead to severe bleeding Into the pelvis Pelvic and acetabular surgery are major surgical interventions
Figura 1- Aplicacioacuten de la engrapadora para la reseccioacuten pulmonar en cuntildea Los segmentos a resecar se limitan por medio de la aplicacioacuten de dispositivos de grapado orientados en direcciones perpendiculares tratando de mantener la mayor cantidad de tejido sano
Insercioacuten de engrapadora lineal cortante a traveacutes de los orificios del tracto de la herida pulmonar penetrante
Figura 3- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales con fuga aeacuterea visible
Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales
Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
- Slide 1
- Slide 2
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
- Slide 10
- Slide 11
- Slide 12
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- Slide 31
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Slide 36
- Slide 37
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
WAIT AND SEE
SURGEON
ABDOMINAL PACKING is a lifesaving technique for temporary control of severe injury and it is used in damage control surgery schedule
Its possible too applying packs in organ-specific techniques (early abdominal packing)
The median survival of the 70 certainly superior to the obtainable survival with immediate surgical repairbullIMMEDIATE FAILURES are substantially due to bleeding especially in underpacking caseREMOTE FAILURES septic and bound at the time of stay (above the 72 hours) and associated by the coexistence of lesions in these situations is possible a MOF syndrome due to excessive intra-abdominal pressure (overpacking) or to an Abdominal Compartment Syndrome
Stagnitti F Bresadola L Calderale SM Coletti M Ribaldi S Salvi PF Schillaci F Abdominal packing indications and method Ann Ital Chir 2003 Sep-Oct74(5)535-42
Benavides C Garciacutea C Apablaza S Rubilar P Ricaurte F Perales C et al Empaquetamiento hepaacutetico permanente con malla de poliglactina en estallido hepaacutetico secundario a Siacutendrome de Hellp Rev Chil Cir 2004 56 275-278 De la Fuente M Mendoza VH Robledo-Oyarzun F Cierre Temporal de la pared abdominal con polietileno Cir Ciruj 2002 70157-63 Serna VH El Siacutendrome Compartamental Abdominal Tesis de Postgrado Meacutexico 2000
When skin approximation is
not possible a temporary silo
is constructed by suturing a 3-
L cystoscopy irrigation bag
(BOGOTAacute BAG) to the skin
edge with a continuous No 2
nylon suture
The method of closure depends on whether skin approximation produces excessive intra-abdominal hypertension
Towel-clip closure of the skin is preferred because it is quick and easy
The second phase is intra-operative reassessment for hemorrhage control 30 minutes after initial abdominal closure in the operating room focusing on restoration of the patients physiological status specifically reversing hypothermia and coagulopathy
WE CAN HEAR THE HEMORRHAGE
The abdomen is then reopened and assessed for adequacy of hemostasis and for existence of residual mechanical bleeding This practice has allowed surgeons to minimize both early return to the operating room for ongoing hemorrhage and the amount of packing necessary for hemostasis With bleeding effectively controlled the abdomen is reclosed
The patient is transferred to the ICU for continued physiologic restoration in the third phase
Once coagulopathy hypothermia and acidosis have been corrected the patient can be returned to the operating room for definitive management of the injuries in the fourth phase
48-72 h after first surgery
COMPLICATIONS OF DAMAGE CONTROL LAPAROTOMY
1) ACS Acute Compartmental Syndrome
2) ARDS Acute Respiratory Distress of the Adult
3) MOF Multiple organ failure
4) DEATH
ABDOMINAL COMPARTMENT SYNDROME is defined as an intra-abdominal pressure of greater than 20 cm H2O with evidence of impaired organ function ie elevated peak airway pressures (gt45 cm
H2O) oliguria (lt05 mLkg per hour) or cardiovascular dysfunction
(hypotension despite adequate volume resuscitation or if a pulmonary artery catheter is present oxygen delivery index [calculated as milliliters of oxygen per minute per meter squared] of 600) Intra-abdominal pressure was measured indirectly using an indwelling Foley catheter as previously described
Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13 Damage control surgery in the abdomen an approach for the management of severe injured patientsGermanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis NNuffield Department of Surgery John Radcliffe Hospital Oxford UK Curr Opin Crit Care 2006 Aug12(4)346-50 Damage-control laparotomy Lee JC Peitzman AB Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA
ABDOMINAL COMPARTMENT SYNDROME occurred in 17 (33) of
52 Patients undergoing damage-control laparotomy and was
associated with a much higher incidence of ARDS and MOF (71 vs
31 without ACS P = 02)
More importantly our study suggests that primary fascial closure at
the termination of the initial damage-control laparotomy contributes to
the development of ACS as well as subsequent organ failure
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal ypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
Mayberry JC Mullins RJ Crass RA Trunkey DD Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure Arch Surg 1997132957-962
bull MOF Multiple organ failure
Seems to be a major source of postinjury morbidity and the leading cause of in-hospital mortality despite more than 25 years of intense investigation
Eiseman B Beart R Norton L Multiple organ failure Surg Gynecol Obstet 1977144323-326
Bauer AE Durham R Faist E Systemic inflammatory response syndrome (SIRS) multiple organ dysfunction syndrome (MODS) multiple organ failure (MOF) are we winning the battle Shock 19981079-89
The current pathophysiologic model of MOF focuses on uncontrolled systemic
hyperinflammation as a unifying concept following a variety of insults
Moore FA Moore EE Evolving concepts in the pathogenesis of postinjury multiple organ failure Surg Clin North Am 199575257-277
Goris RJ te Boekhorst TP Nuytinck JK Gimbrere JS Multiple-organ failure generalized autodestructive inflammation Arch Surg 19851201109-1115
Nuytinck HK Offermans XJ Kubat K Goris JA Whole-body inflammation in trauma patients an autopsy study Arch Surg 19881231519-1524
Examples that improve the prognosis of MOF include damage control surgery recognition of abdominal compartment syndrome lung protective ventilation
strategies and tight glucose level control
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal hypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
The Acute Respiratory Distress Syndrome Network Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome N Engl J Med 20003421301-1308
Amato MB Barbas CS Medeiros DM et al Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome N Engl J Med 1998338347-354
Van den Berghe G Wouters P Weekers F et al Intensive insulin therapy in the critically ill patients N Engl J Med 20013451359-1367
The incidence of postinjury MOF has been reported to be between 7 and 66 with an associated mortality rate between 31 and 80
Fry DE Pearlstein L Fulton RL Polk HC Jr Multiple system organ failure the role of uncontrolled infection Arch Surg 1980115136-140
Regel G Lobenhoffer P Grotz M Pape HC Lehmann U Tscherne H Treatment results of patients with multiple trauma an analysis of 3406 cases treated between 1972 and 1991 at a German level I trauma center J Trauma 19953870-78
Sauaia A Moore FA Moore EE Norris JM Lezotte DC Hamman RF Multiple organ failure can be predicted as early as 12 hours after injury J Trauma 199845291-303
Nast-Kolb D Aufmkolk M Rucholtz S Obertacke U Waydhas C Multiple organ failure still a major cause of morbidity but not mortality in blunt multiple trauma J Trauma 200151835-842 Durham RM Moran JJ Mazuski JE Shapiro MJ Baue AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
It has been suggested that MOF is disappearing owing to advances in trauma and critical care
Levine JH Durham RM Moran J Bauer A Multiple organ failure is it disappearing World J Surg 199620471-473
Recent reports have not demonstrated a consistent change in either the incidence or the mortality rate associated with postinjury MOF Some groups have reported no change in the incidence but a decreased mortality while others have reported both decreased incidence and mortality compared with historical control subjects
Durham RM Moran JJ Mazuski JE Shapiro MJ Bauer AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
Regel G Grotz M Weltner T Sturm JA Tscherne H Pattern of organ failure following severe trauma World J Surg 199620422-429
Orthopaedic Trauma
Open pelvic fractures in addition to the pelvic ring injury are associated with hemorrhage and neurological insult visceral injuries are more common and a high rate of infection is seen Mortality of open pelvic fractures historically approached 50 Control of bleeding is the most important initial measure followed by debridement and packing of open wounds
Open book- widened symphysis pubis Dislocated Rt SI joint Vallier + Jenkins In Trauma Anesthesia 2008
Type 1 fractures occur due to anterior-posterior
compressioncan cause the symphysis pubis to ldquopoprdquo open leading to pubic rami or ldquoopen
bookrdquo fractures A lateral compression fracture type 2 or vertical sheer facture (Type 3) can
also lead to severe bleeding Into the pelvis Pelvic and acetabular surgery are major surgical interventions
Figura 1- Aplicacioacuten de la engrapadora para la reseccioacuten pulmonar en cuntildea Los segmentos a resecar se limitan por medio de la aplicacioacuten de dispositivos de grapado orientados en direcciones perpendiculares tratando de mantener la mayor cantidad de tejido sano
Insercioacuten de engrapadora lineal cortante a traveacutes de los orificios del tracto de la herida pulmonar penetrante
Figura 3- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales con fuga aeacuterea visible
Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales
Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
- Slide 1
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- Slide 31
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- Slide 35
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- Slide 59
-
ABDOMINAL PACKING is a lifesaving technique for temporary control of severe injury and it is used in damage control surgery schedule
Its possible too applying packs in organ-specific techniques (early abdominal packing)
The median survival of the 70 certainly superior to the obtainable survival with immediate surgical repairbullIMMEDIATE FAILURES are substantially due to bleeding especially in underpacking caseREMOTE FAILURES septic and bound at the time of stay (above the 72 hours) and associated by the coexistence of lesions in these situations is possible a MOF syndrome due to excessive intra-abdominal pressure (overpacking) or to an Abdominal Compartment Syndrome
Stagnitti F Bresadola L Calderale SM Coletti M Ribaldi S Salvi PF Schillaci F Abdominal packing indications and method Ann Ital Chir 2003 Sep-Oct74(5)535-42
Benavides C Garciacutea C Apablaza S Rubilar P Ricaurte F Perales C et al Empaquetamiento hepaacutetico permanente con malla de poliglactina en estallido hepaacutetico secundario a Siacutendrome de Hellp Rev Chil Cir 2004 56 275-278 De la Fuente M Mendoza VH Robledo-Oyarzun F Cierre Temporal de la pared abdominal con polietileno Cir Ciruj 2002 70157-63 Serna VH El Siacutendrome Compartamental Abdominal Tesis de Postgrado Meacutexico 2000
When skin approximation is
not possible a temporary silo
is constructed by suturing a 3-
L cystoscopy irrigation bag
(BOGOTAacute BAG) to the skin
edge with a continuous No 2
nylon suture
The method of closure depends on whether skin approximation produces excessive intra-abdominal hypertension
Towel-clip closure of the skin is preferred because it is quick and easy
The second phase is intra-operative reassessment for hemorrhage control 30 minutes after initial abdominal closure in the operating room focusing on restoration of the patients physiological status specifically reversing hypothermia and coagulopathy
WE CAN HEAR THE HEMORRHAGE
The abdomen is then reopened and assessed for adequacy of hemostasis and for existence of residual mechanical bleeding This practice has allowed surgeons to minimize both early return to the operating room for ongoing hemorrhage and the amount of packing necessary for hemostasis With bleeding effectively controlled the abdomen is reclosed
The patient is transferred to the ICU for continued physiologic restoration in the third phase
Once coagulopathy hypothermia and acidosis have been corrected the patient can be returned to the operating room for definitive management of the injuries in the fourth phase
48-72 h after first surgery
COMPLICATIONS OF DAMAGE CONTROL LAPAROTOMY
1) ACS Acute Compartmental Syndrome
2) ARDS Acute Respiratory Distress of the Adult
3) MOF Multiple organ failure
4) DEATH
ABDOMINAL COMPARTMENT SYNDROME is defined as an intra-abdominal pressure of greater than 20 cm H2O with evidence of impaired organ function ie elevated peak airway pressures (gt45 cm
H2O) oliguria (lt05 mLkg per hour) or cardiovascular dysfunction
(hypotension despite adequate volume resuscitation or if a pulmonary artery catheter is present oxygen delivery index [calculated as milliliters of oxygen per minute per meter squared] of 600) Intra-abdominal pressure was measured indirectly using an indwelling Foley catheter as previously described
Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13 Damage control surgery in the abdomen an approach for the management of severe injured patientsGermanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis NNuffield Department of Surgery John Radcliffe Hospital Oxford UK Curr Opin Crit Care 2006 Aug12(4)346-50 Damage-control laparotomy Lee JC Peitzman AB Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA
ABDOMINAL COMPARTMENT SYNDROME occurred in 17 (33) of
52 Patients undergoing damage-control laparotomy and was
associated with a much higher incidence of ARDS and MOF (71 vs
31 without ACS P = 02)
More importantly our study suggests that primary fascial closure at
the termination of the initial damage-control laparotomy contributes to
the development of ACS as well as subsequent organ failure
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal ypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
Mayberry JC Mullins RJ Crass RA Trunkey DD Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure Arch Surg 1997132957-962
bull MOF Multiple organ failure
Seems to be a major source of postinjury morbidity and the leading cause of in-hospital mortality despite more than 25 years of intense investigation
Eiseman B Beart R Norton L Multiple organ failure Surg Gynecol Obstet 1977144323-326
Bauer AE Durham R Faist E Systemic inflammatory response syndrome (SIRS) multiple organ dysfunction syndrome (MODS) multiple organ failure (MOF) are we winning the battle Shock 19981079-89
The current pathophysiologic model of MOF focuses on uncontrolled systemic
hyperinflammation as a unifying concept following a variety of insults
Moore FA Moore EE Evolving concepts in the pathogenesis of postinjury multiple organ failure Surg Clin North Am 199575257-277
Goris RJ te Boekhorst TP Nuytinck JK Gimbrere JS Multiple-organ failure generalized autodestructive inflammation Arch Surg 19851201109-1115
Nuytinck HK Offermans XJ Kubat K Goris JA Whole-body inflammation in trauma patients an autopsy study Arch Surg 19881231519-1524
Examples that improve the prognosis of MOF include damage control surgery recognition of abdominal compartment syndrome lung protective ventilation
strategies and tight glucose level control
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal hypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
The Acute Respiratory Distress Syndrome Network Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome N Engl J Med 20003421301-1308
Amato MB Barbas CS Medeiros DM et al Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome N Engl J Med 1998338347-354
Van den Berghe G Wouters P Weekers F et al Intensive insulin therapy in the critically ill patients N Engl J Med 20013451359-1367
The incidence of postinjury MOF has been reported to be between 7 and 66 with an associated mortality rate between 31 and 80
Fry DE Pearlstein L Fulton RL Polk HC Jr Multiple system organ failure the role of uncontrolled infection Arch Surg 1980115136-140
Regel G Lobenhoffer P Grotz M Pape HC Lehmann U Tscherne H Treatment results of patients with multiple trauma an analysis of 3406 cases treated between 1972 and 1991 at a German level I trauma center J Trauma 19953870-78
Sauaia A Moore FA Moore EE Norris JM Lezotte DC Hamman RF Multiple organ failure can be predicted as early as 12 hours after injury J Trauma 199845291-303
Nast-Kolb D Aufmkolk M Rucholtz S Obertacke U Waydhas C Multiple organ failure still a major cause of morbidity but not mortality in blunt multiple trauma J Trauma 200151835-842 Durham RM Moran JJ Mazuski JE Shapiro MJ Baue AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
It has been suggested that MOF is disappearing owing to advances in trauma and critical care
Levine JH Durham RM Moran J Bauer A Multiple organ failure is it disappearing World J Surg 199620471-473
Recent reports have not demonstrated a consistent change in either the incidence or the mortality rate associated with postinjury MOF Some groups have reported no change in the incidence but a decreased mortality while others have reported both decreased incidence and mortality compared with historical control subjects
Durham RM Moran JJ Mazuski JE Shapiro MJ Bauer AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
Regel G Grotz M Weltner T Sturm JA Tscherne H Pattern of organ failure following severe trauma World J Surg 199620422-429
Orthopaedic Trauma
Open pelvic fractures in addition to the pelvic ring injury are associated with hemorrhage and neurological insult visceral injuries are more common and a high rate of infection is seen Mortality of open pelvic fractures historically approached 50 Control of bleeding is the most important initial measure followed by debridement and packing of open wounds
Open book- widened symphysis pubis Dislocated Rt SI joint Vallier + Jenkins In Trauma Anesthesia 2008
Type 1 fractures occur due to anterior-posterior
compressioncan cause the symphysis pubis to ldquopoprdquo open leading to pubic rami or ldquoopen
bookrdquo fractures A lateral compression fracture type 2 or vertical sheer facture (Type 3) can
also lead to severe bleeding Into the pelvis Pelvic and acetabular surgery are major surgical interventions
Figura 1- Aplicacioacuten de la engrapadora para la reseccioacuten pulmonar en cuntildea Los segmentos a resecar se limitan por medio de la aplicacioacuten de dispositivos de grapado orientados en direcciones perpendiculares tratando de mantener la mayor cantidad de tejido sano
Insercioacuten de engrapadora lineal cortante a traveacutes de los orificios del tracto de la herida pulmonar penetrante
Figura 3- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales con fuga aeacuterea visible
Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales
Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
- Slide 1
- Slide 2
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
- Slide 10
- Slide 11
- Slide 12
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- Slide 31
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Slide 36
- Slide 37
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
Benavides C Garciacutea C Apablaza S Rubilar P Ricaurte F Perales C et al Empaquetamiento hepaacutetico permanente con malla de poliglactina en estallido hepaacutetico secundario a Siacutendrome de Hellp Rev Chil Cir 2004 56 275-278 De la Fuente M Mendoza VH Robledo-Oyarzun F Cierre Temporal de la pared abdominal con polietileno Cir Ciruj 2002 70157-63 Serna VH El Siacutendrome Compartamental Abdominal Tesis de Postgrado Meacutexico 2000
When skin approximation is
not possible a temporary silo
is constructed by suturing a 3-
L cystoscopy irrigation bag
(BOGOTAacute BAG) to the skin
edge with a continuous No 2
nylon suture
The method of closure depends on whether skin approximation produces excessive intra-abdominal hypertension
Towel-clip closure of the skin is preferred because it is quick and easy
The second phase is intra-operative reassessment for hemorrhage control 30 minutes after initial abdominal closure in the operating room focusing on restoration of the patients physiological status specifically reversing hypothermia and coagulopathy
WE CAN HEAR THE HEMORRHAGE
The abdomen is then reopened and assessed for adequacy of hemostasis and for existence of residual mechanical bleeding This practice has allowed surgeons to minimize both early return to the operating room for ongoing hemorrhage and the amount of packing necessary for hemostasis With bleeding effectively controlled the abdomen is reclosed
The patient is transferred to the ICU for continued physiologic restoration in the third phase
Once coagulopathy hypothermia and acidosis have been corrected the patient can be returned to the operating room for definitive management of the injuries in the fourth phase
48-72 h after first surgery
COMPLICATIONS OF DAMAGE CONTROL LAPAROTOMY
1) ACS Acute Compartmental Syndrome
2) ARDS Acute Respiratory Distress of the Adult
3) MOF Multiple organ failure
4) DEATH
ABDOMINAL COMPARTMENT SYNDROME is defined as an intra-abdominal pressure of greater than 20 cm H2O with evidence of impaired organ function ie elevated peak airway pressures (gt45 cm
H2O) oliguria (lt05 mLkg per hour) or cardiovascular dysfunction
(hypotension despite adequate volume resuscitation or if a pulmonary artery catheter is present oxygen delivery index [calculated as milliliters of oxygen per minute per meter squared] of 600) Intra-abdominal pressure was measured indirectly using an indwelling Foley catheter as previously described
Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13 Damage control surgery in the abdomen an approach for the management of severe injured patientsGermanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis NNuffield Department of Surgery John Radcliffe Hospital Oxford UK Curr Opin Crit Care 2006 Aug12(4)346-50 Damage-control laparotomy Lee JC Peitzman AB Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA
ABDOMINAL COMPARTMENT SYNDROME occurred in 17 (33) of
52 Patients undergoing damage-control laparotomy and was
associated with a much higher incidence of ARDS and MOF (71 vs
31 without ACS P = 02)
More importantly our study suggests that primary fascial closure at
the termination of the initial damage-control laparotomy contributes to
the development of ACS as well as subsequent organ failure
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal ypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
Mayberry JC Mullins RJ Crass RA Trunkey DD Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure Arch Surg 1997132957-962
bull MOF Multiple organ failure
Seems to be a major source of postinjury morbidity and the leading cause of in-hospital mortality despite more than 25 years of intense investigation
Eiseman B Beart R Norton L Multiple organ failure Surg Gynecol Obstet 1977144323-326
Bauer AE Durham R Faist E Systemic inflammatory response syndrome (SIRS) multiple organ dysfunction syndrome (MODS) multiple organ failure (MOF) are we winning the battle Shock 19981079-89
The current pathophysiologic model of MOF focuses on uncontrolled systemic
hyperinflammation as a unifying concept following a variety of insults
Moore FA Moore EE Evolving concepts in the pathogenesis of postinjury multiple organ failure Surg Clin North Am 199575257-277
Goris RJ te Boekhorst TP Nuytinck JK Gimbrere JS Multiple-organ failure generalized autodestructive inflammation Arch Surg 19851201109-1115
Nuytinck HK Offermans XJ Kubat K Goris JA Whole-body inflammation in trauma patients an autopsy study Arch Surg 19881231519-1524
Examples that improve the prognosis of MOF include damage control surgery recognition of abdominal compartment syndrome lung protective ventilation
strategies and tight glucose level control
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal hypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
The Acute Respiratory Distress Syndrome Network Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome N Engl J Med 20003421301-1308
Amato MB Barbas CS Medeiros DM et al Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome N Engl J Med 1998338347-354
Van den Berghe G Wouters P Weekers F et al Intensive insulin therapy in the critically ill patients N Engl J Med 20013451359-1367
The incidence of postinjury MOF has been reported to be between 7 and 66 with an associated mortality rate between 31 and 80
Fry DE Pearlstein L Fulton RL Polk HC Jr Multiple system organ failure the role of uncontrolled infection Arch Surg 1980115136-140
Regel G Lobenhoffer P Grotz M Pape HC Lehmann U Tscherne H Treatment results of patients with multiple trauma an analysis of 3406 cases treated between 1972 and 1991 at a German level I trauma center J Trauma 19953870-78
Sauaia A Moore FA Moore EE Norris JM Lezotte DC Hamman RF Multiple organ failure can be predicted as early as 12 hours after injury J Trauma 199845291-303
Nast-Kolb D Aufmkolk M Rucholtz S Obertacke U Waydhas C Multiple organ failure still a major cause of morbidity but not mortality in blunt multiple trauma J Trauma 200151835-842 Durham RM Moran JJ Mazuski JE Shapiro MJ Baue AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
It has been suggested that MOF is disappearing owing to advances in trauma and critical care
Levine JH Durham RM Moran J Bauer A Multiple organ failure is it disappearing World J Surg 199620471-473
Recent reports have not demonstrated a consistent change in either the incidence or the mortality rate associated with postinjury MOF Some groups have reported no change in the incidence but a decreased mortality while others have reported both decreased incidence and mortality compared with historical control subjects
Durham RM Moran JJ Mazuski JE Shapiro MJ Bauer AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
Regel G Grotz M Weltner T Sturm JA Tscherne H Pattern of organ failure following severe trauma World J Surg 199620422-429
Orthopaedic Trauma
Open pelvic fractures in addition to the pelvic ring injury are associated with hemorrhage and neurological insult visceral injuries are more common and a high rate of infection is seen Mortality of open pelvic fractures historically approached 50 Control of bleeding is the most important initial measure followed by debridement and packing of open wounds
Open book- widened symphysis pubis Dislocated Rt SI joint Vallier + Jenkins In Trauma Anesthesia 2008
Type 1 fractures occur due to anterior-posterior
compressioncan cause the symphysis pubis to ldquopoprdquo open leading to pubic rami or ldquoopen
bookrdquo fractures A lateral compression fracture type 2 or vertical sheer facture (Type 3) can
also lead to severe bleeding Into the pelvis Pelvic and acetabular surgery are major surgical interventions
Figura 1- Aplicacioacuten de la engrapadora para la reseccioacuten pulmonar en cuntildea Los segmentos a resecar se limitan por medio de la aplicacioacuten de dispositivos de grapado orientados en direcciones perpendiculares tratando de mantener la mayor cantidad de tejido sano
Insercioacuten de engrapadora lineal cortante a traveacutes de los orificios del tracto de la herida pulmonar penetrante
Figura 3- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales con fuga aeacuterea visible
Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales
Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
- Slide 1
- Slide 2
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
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- Slide 58
- Slide 59
-
The method of closure depends on whether skin approximation produces excessive intra-abdominal hypertension
Towel-clip closure of the skin is preferred because it is quick and easy
The second phase is intra-operative reassessment for hemorrhage control 30 minutes after initial abdominal closure in the operating room focusing on restoration of the patients physiological status specifically reversing hypothermia and coagulopathy
WE CAN HEAR THE HEMORRHAGE
The abdomen is then reopened and assessed for adequacy of hemostasis and for existence of residual mechanical bleeding This practice has allowed surgeons to minimize both early return to the operating room for ongoing hemorrhage and the amount of packing necessary for hemostasis With bleeding effectively controlled the abdomen is reclosed
The patient is transferred to the ICU for continued physiologic restoration in the third phase
Once coagulopathy hypothermia and acidosis have been corrected the patient can be returned to the operating room for definitive management of the injuries in the fourth phase
48-72 h after first surgery
COMPLICATIONS OF DAMAGE CONTROL LAPAROTOMY
1) ACS Acute Compartmental Syndrome
2) ARDS Acute Respiratory Distress of the Adult
3) MOF Multiple organ failure
4) DEATH
ABDOMINAL COMPARTMENT SYNDROME is defined as an intra-abdominal pressure of greater than 20 cm H2O with evidence of impaired organ function ie elevated peak airway pressures (gt45 cm
H2O) oliguria (lt05 mLkg per hour) or cardiovascular dysfunction
(hypotension despite adequate volume resuscitation or if a pulmonary artery catheter is present oxygen delivery index [calculated as milliliters of oxygen per minute per meter squared] of 600) Intra-abdominal pressure was measured indirectly using an indwelling Foley catheter as previously described
Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13 Damage control surgery in the abdomen an approach for the management of severe injured patientsGermanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis NNuffield Department of Surgery John Radcliffe Hospital Oxford UK Curr Opin Crit Care 2006 Aug12(4)346-50 Damage-control laparotomy Lee JC Peitzman AB Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA
ABDOMINAL COMPARTMENT SYNDROME occurred in 17 (33) of
52 Patients undergoing damage-control laparotomy and was
associated with a much higher incidence of ARDS and MOF (71 vs
31 without ACS P = 02)
More importantly our study suggests that primary fascial closure at
the termination of the initial damage-control laparotomy contributes to
the development of ACS as well as subsequent organ failure
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal ypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
Mayberry JC Mullins RJ Crass RA Trunkey DD Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure Arch Surg 1997132957-962
bull MOF Multiple organ failure
Seems to be a major source of postinjury morbidity and the leading cause of in-hospital mortality despite more than 25 years of intense investigation
Eiseman B Beart R Norton L Multiple organ failure Surg Gynecol Obstet 1977144323-326
Bauer AE Durham R Faist E Systemic inflammatory response syndrome (SIRS) multiple organ dysfunction syndrome (MODS) multiple organ failure (MOF) are we winning the battle Shock 19981079-89
The current pathophysiologic model of MOF focuses on uncontrolled systemic
hyperinflammation as a unifying concept following a variety of insults
Moore FA Moore EE Evolving concepts in the pathogenesis of postinjury multiple organ failure Surg Clin North Am 199575257-277
Goris RJ te Boekhorst TP Nuytinck JK Gimbrere JS Multiple-organ failure generalized autodestructive inflammation Arch Surg 19851201109-1115
Nuytinck HK Offermans XJ Kubat K Goris JA Whole-body inflammation in trauma patients an autopsy study Arch Surg 19881231519-1524
Examples that improve the prognosis of MOF include damage control surgery recognition of abdominal compartment syndrome lung protective ventilation
strategies and tight glucose level control
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal hypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
The Acute Respiratory Distress Syndrome Network Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome N Engl J Med 20003421301-1308
Amato MB Barbas CS Medeiros DM et al Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome N Engl J Med 1998338347-354
Van den Berghe G Wouters P Weekers F et al Intensive insulin therapy in the critically ill patients N Engl J Med 20013451359-1367
The incidence of postinjury MOF has been reported to be between 7 and 66 with an associated mortality rate between 31 and 80
Fry DE Pearlstein L Fulton RL Polk HC Jr Multiple system organ failure the role of uncontrolled infection Arch Surg 1980115136-140
Regel G Lobenhoffer P Grotz M Pape HC Lehmann U Tscherne H Treatment results of patients with multiple trauma an analysis of 3406 cases treated between 1972 and 1991 at a German level I trauma center J Trauma 19953870-78
Sauaia A Moore FA Moore EE Norris JM Lezotte DC Hamman RF Multiple organ failure can be predicted as early as 12 hours after injury J Trauma 199845291-303
Nast-Kolb D Aufmkolk M Rucholtz S Obertacke U Waydhas C Multiple organ failure still a major cause of morbidity but not mortality in blunt multiple trauma J Trauma 200151835-842 Durham RM Moran JJ Mazuski JE Shapiro MJ Baue AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
It has been suggested that MOF is disappearing owing to advances in trauma and critical care
Levine JH Durham RM Moran J Bauer A Multiple organ failure is it disappearing World J Surg 199620471-473
Recent reports have not demonstrated a consistent change in either the incidence or the mortality rate associated with postinjury MOF Some groups have reported no change in the incidence but a decreased mortality while others have reported both decreased incidence and mortality compared with historical control subjects
Durham RM Moran JJ Mazuski JE Shapiro MJ Bauer AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
Regel G Grotz M Weltner T Sturm JA Tscherne H Pattern of organ failure following severe trauma World J Surg 199620422-429
Orthopaedic Trauma
Open pelvic fractures in addition to the pelvic ring injury are associated with hemorrhage and neurological insult visceral injuries are more common and a high rate of infection is seen Mortality of open pelvic fractures historically approached 50 Control of bleeding is the most important initial measure followed by debridement and packing of open wounds
Open book- widened symphysis pubis Dislocated Rt SI joint Vallier + Jenkins In Trauma Anesthesia 2008
Type 1 fractures occur due to anterior-posterior
compressioncan cause the symphysis pubis to ldquopoprdquo open leading to pubic rami or ldquoopen
bookrdquo fractures A lateral compression fracture type 2 or vertical sheer facture (Type 3) can
also lead to severe bleeding Into the pelvis Pelvic and acetabular surgery are major surgical interventions
Figura 1- Aplicacioacuten de la engrapadora para la reseccioacuten pulmonar en cuntildea Los segmentos a resecar se limitan por medio de la aplicacioacuten de dispositivos de grapado orientados en direcciones perpendiculares tratando de mantener la mayor cantidad de tejido sano
Insercioacuten de engrapadora lineal cortante a traveacutes de los orificios del tracto de la herida pulmonar penetrante
Figura 3- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales con fuga aeacuterea visible
Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales
Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
- Slide 1
- Slide 2
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
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- Slide 31
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- Slide 33
- Slide 34
- Slide 35
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- Slide 37
- Slide 38
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- Slide 40
- Slide 41
- Slide 42
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- Slide 44
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- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
The second phase is intra-operative reassessment for hemorrhage control 30 minutes after initial abdominal closure in the operating room focusing on restoration of the patients physiological status specifically reversing hypothermia and coagulopathy
WE CAN HEAR THE HEMORRHAGE
The abdomen is then reopened and assessed for adequacy of hemostasis and for existence of residual mechanical bleeding This practice has allowed surgeons to minimize both early return to the operating room for ongoing hemorrhage and the amount of packing necessary for hemostasis With bleeding effectively controlled the abdomen is reclosed
The patient is transferred to the ICU for continued physiologic restoration in the third phase
Once coagulopathy hypothermia and acidosis have been corrected the patient can be returned to the operating room for definitive management of the injuries in the fourth phase
48-72 h after first surgery
COMPLICATIONS OF DAMAGE CONTROL LAPAROTOMY
1) ACS Acute Compartmental Syndrome
2) ARDS Acute Respiratory Distress of the Adult
3) MOF Multiple organ failure
4) DEATH
ABDOMINAL COMPARTMENT SYNDROME is defined as an intra-abdominal pressure of greater than 20 cm H2O with evidence of impaired organ function ie elevated peak airway pressures (gt45 cm
H2O) oliguria (lt05 mLkg per hour) or cardiovascular dysfunction
(hypotension despite adequate volume resuscitation or if a pulmonary artery catheter is present oxygen delivery index [calculated as milliliters of oxygen per minute per meter squared] of 600) Intra-abdominal pressure was measured indirectly using an indwelling Foley catheter as previously described
Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13 Damage control surgery in the abdomen an approach for the management of severe injured patientsGermanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis NNuffield Department of Surgery John Radcliffe Hospital Oxford UK Curr Opin Crit Care 2006 Aug12(4)346-50 Damage-control laparotomy Lee JC Peitzman AB Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA
ABDOMINAL COMPARTMENT SYNDROME occurred in 17 (33) of
52 Patients undergoing damage-control laparotomy and was
associated with a much higher incidence of ARDS and MOF (71 vs
31 without ACS P = 02)
More importantly our study suggests that primary fascial closure at
the termination of the initial damage-control laparotomy contributes to
the development of ACS as well as subsequent organ failure
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal ypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
Mayberry JC Mullins RJ Crass RA Trunkey DD Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure Arch Surg 1997132957-962
bull MOF Multiple organ failure
Seems to be a major source of postinjury morbidity and the leading cause of in-hospital mortality despite more than 25 years of intense investigation
Eiseman B Beart R Norton L Multiple organ failure Surg Gynecol Obstet 1977144323-326
Bauer AE Durham R Faist E Systemic inflammatory response syndrome (SIRS) multiple organ dysfunction syndrome (MODS) multiple organ failure (MOF) are we winning the battle Shock 19981079-89
The current pathophysiologic model of MOF focuses on uncontrolled systemic
hyperinflammation as a unifying concept following a variety of insults
Moore FA Moore EE Evolving concepts in the pathogenesis of postinjury multiple organ failure Surg Clin North Am 199575257-277
Goris RJ te Boekhorst TP Nuytinck JK Gimbrere JS Multiple-organ failure generalized autodestructive inflammation Arch Surg 19851201109-1115
Nuytinck HK Offermans XJ Kubat K Goris JA Whole-body inflammation in trauma patients an autopsy study Arch Surg 19881231519-1524
Examples that improve the prognosis of MOF include damage control surgery recognition of abdominal compartment syndrome lung protective ventilation
strategies and tight glucose level control
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal hypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
The Acute Respiratory Distress Syndrome Network Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome N Engl J Med 20003421301-1308
Amato MB Barbas CS Medeiros DM et al Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome N Engl J Med 1998338347-354
Van den Berghe G Wouters P Weekers F et al Intensive insulin therapy in the critically ill patients N Engl J Med 20013451359-1367
The incidence of postinjury MOF has been reported to be between 7 and 66 with an associated mortality rate between 31 and 80
Fry DE Pearlstein L Fulton RL Polk HC Jr Multiple system organ failure the role of uncontrolled infection Arch Surg 1980115136-140
Regel G Lobenhoffer P Grotz M Pape HC Lehmann U Tscherne H Treatment results of patients with multiple trauma an analysis of 3406 cases treated between 1972 and 1991 at a German level I trauma center J Trauma 19953870-78
Sauaia A Moore FA Moore EE Norris JM Lezotte DC Hamman RF Multiple organ failure can be predicted as early as 12 hours after injury J Trauma 199845291-303
Nast-Kolb D Aufmkolk M Rucholtz S Obertacke U Waydhas C Multiple organ failure still a major cause of morbidity but not mortality in blunt multiple trauma J Trauma 200151835-842 Durham RM Moran JJ Mazuski JE Shapiro MJ Baue AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
It has been suggested that MOF is disappearing owing to advances in trauma and critical care
Levine JH Durham RM Moran J Bauer A Multiple organ failure is it disappearing World J Surg 199620471-473
Recent reports have not demonstrated a consistent change in either the incidence or the mortality rate associated with postinjury MOF Some groups have reported no change in the incidence but a decreased mortality while others have reported both decreased incidence and mortality compared with historical control subjects
Durham RM Moran JJ Mazuski JE Shapiro MJ Bauer AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
Regel G Grotz M Weltner T Sturm JA Tscherne H Pattern of organ failure following severe trauma World J Surg 199620422-429
Orthopaedic Trauma
Open pelvic fractures in addition to the pelvic ring injury are associated with hemorrhage and neurological insult visceral injuries are more common and a high rate of infection is seen Mortality of open pelvic fractures historically approached 50 Control of bleeding is the most important initial measure followed by debridement and packing of open wounds
Open book- widened symphysis pubis Dislocated Rt SI joint Vallier + Jenkins In Trauma Anesthesia 2008
Type 1 fractures occur due to anterior-posterior
compressioncan cause the symphysis pubis to ldquopoprdquo open leading to pubic rami or ldquoopen
bookrdquo fractures A lateral compression fracture type 2 or vertical sheer facture (Type 3) can
also lead to severe bleeding Into the pelvis Pelvic and acetabular surgery are major surgical interventions
Figura 1- Aplicacioacuten de la engrapadora para la reseccioacuten pulmonar en cuntildea Los segmentos a resecar se limitan por medio de la aplicacioacuten de dispositivos de grapado orientados en direcciones perpendiculares tratando de mantener la mayor cantidad de tejido sano
Insercioacuten de engrapadora lineal cortante a traveacutes de los orificios del tracto de la herida pulmonar penetrante
Figura 3- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales con fuga aeacuterea visible
Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales
Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
- Slide 1
- Slide 2
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
- Slide 10
- Slide 11
- Slide 12
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- Slide 31
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Slide 36
- Slide 37
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Slide 44
- Slide 45
- Slide 46
- Slide 47
- Slide 48
- Slide 49
- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
The abdomen is then reopened and assessed for adequacy of hemostasis and for existence of residual mechanical bleeding This practice has allowed surgeons to minimize both early return to the operating room for ongoing hemorrhage and the amount of packing necessary for hemostasis With bleeding effectively controlled the abdomen is reclosed
The patient is transferred to the ICU for continued physiologic restoration in the third phase
Once coagulopathy hypothermia and acidosis have been corrected the patient can be returned to the operating room for definitive management of the injuries in the fourth phase
48-72 h after first surgery
COMPLICATIONS OF DAMAGE CONTROL LAPAROTOMY
1) ACS Acute Compartmental Syndrome
2) ARDS Acute Respiratory Distress of the Adult
3) MOF Multiple organ failure
4) DEATH
ABDOMINAL COMPARTMENT SYNDROME is defined as an intra-abdominal pressure of greater than 20 cm H2O with evidence of impaired organ function ie elevated peak airway pressures (gt45 cm
H2O) oliguria (lt05 mLkg per hour) or cardiovascular dysfunction
(hypotension despite adequate volume resuscitation or if a pulmonary artery catheter is present oxygen delivery index [calculated as milliliters of oxygen per minute per meter squared] of 600) Intra-abdominal pressure was measured indirectly using an indwelling Foley catheter as previously described
Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13 Damage control surgery in the abdomen an approach for the management of severe injured patientsGermanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis NNuffield Department of Surgery John Radcliffe Hospital Oxford UK Curr Opin Crit Care 2006 Aug12(4)346-50 Damage-control laparotomy Lee JC Peitzman AB Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA
ABDOMINAL COMPARTMENT SYNDROME occurred in 17 (33) of
52 Patients undergoing damage-control laparotomy and was
associated with a much higher incidence of ARDS and MOF (71 vs
31 without ACS P = 02)
More importantly our study suggests that primary fascial closure at
the termination of the initial damage-control laparotomy contributes to
the development of ACS as well as subsequent organ failure
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal ypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
Mayberry JC Mullins RJ Crass RA Trunkey DD Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure Arch Surg 1997132957-962
bull MOF Multiple organ failure
Seems to be a major source of postinjury morbidity and the leading cause of in-hospital mortality despite more than 25 years of intense investigation
Eiseman B Beart R Norton L Multiple organ failure Surg Gynecol Obstet 1977144323-326
Bauer AE Durham R Faist E Systemic inflammatory response syndrome (SIRS) multiple organ dysfunction syndrome (MODS) multiple organ failure (MOF) are we winning the battle Shock 19981079-89
The current pathophysiologic model of MOF focuses on uncontrolled systemic
hyperinflammation as a unifying concept following a variety of insults
Moore FA Moore EE Evolving concepts in the pathogenesis of postinjury multiple organ failure Surg Clin North Am 199575257-277
Goris RJ te Boekhorst TP Nuytinck JK Gimbrere JS Multiple-organ failure generalized autodestructive inflammation Arch Surg 19851201109-1115
Nuytinck HK Offermans XJ Kubat K Goris JA Whole-body inflammation in trauma patients an autopsy study Arch Surg 19881231519-1524
Examples that improve the prognosis of MOF include damage control surgery recognition of abdominal compartment syndrome lung protective ventilation
strategies and tight glucose level control
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal hypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
The Acute Respiratory Distress Syndrome Network Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome N Engl J Med 20003421301-1308
Amato MB Barbas CS Medeiros DM et al Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome N Engl J Med 1998338347-354
Van den Berghe G Wouters P Weekers F et al Intensive insulin therapy in the critically ill patients N Engl J Med 20013451359-1367
The incidence of postinjury MOF has been reported to be between 7 and 66 with an associated mortality rate between 31 and 80
Fry DE Pearlstein L Fulton RL Polk HC Jr Multiple system organ failure the role of uncontrolled infection Arch Surg 1980115136-140
Regel G Lobenhoffer P Grotz M Pape HC Lehmann U Tscherne H Treatment results of patients with multiple trauma an analysis of 3406 cases treated between 1972 and 1991 at a German level I trauma center J Trauma 19953870-78
Sauaia A Moore FA Moore EE Norris JM Lezotte DC Hamman RF Multiple organ failure can be predicted as early as 12 hours after injury J Trauma 199845291-303
Nast-Kolb D Aufmkolk M Rucholtz S Obertacke U Waydhas C Multiple organ failure still a major cause of morbidity but not mortality in blunt multiple trauma J Trauma 200151835-842 Durham RM Moran JJ Mazuski JE Shapiro MJ Baue AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
It has been suggested that MOF is disappearing owing to advances in trauma and critical care
Levine JH Durham RM Moran J Bauer A Multiple organ failure is it disappearing World J Surg 199620471-473
Recent reports have not demonstrated a consistent change in either the incidence or the mortality rate associated with postinjury MOF Some groups have reported no change in the incidence but a decreased mortality while others have reported both decreased incidence and mortality compared with historical control subjects
Durham RM Moran JJ Mazuski JE Shapiro MJ Bauer AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
Regel G Grotz M Weltner T Sturm JA Tscherne H Pattern of organ failure following severe trauma World J Surg 199620422-429
Orthopaedic Trauma
Open pelvic fractures in addition to the pelvic ring injury are associated with hemorrhage and neurological insult visceral injuries are more common and a high rate of infection is seen Mortality of open pelvic fractures historically approached 50 Control of bleeding is the most important initial measure followed by debridement and packing of open wounds
Open book- widened symphysis pubis Dislocated Rt SI joint Vallier + Jenkins In Trauma Anesthesia 2008
Type 1 fractures occur due to anterior-posterior
compressioncan cause the symphysis pubis to ldquopoprdquo open leading to pubic rami or ldquoopen
bookrdquo fractures A lateral compression fracture type 2 or vertical sheer facture (Type 3) can
also lead to severe bleeding Into the pelvis Pelvic and acetabular surgery are major surgical interventions
Figura 1- Aplicacioacuten de la engrapadora para la reseccioacuten pulmonar en cuntildea Los segmentos a resecar se limitan por medio de la aplicacioacuten de dispositivos de grapado orientados en direcciones perpendiculares tratando de mantener la mayor cantidad de tejido sano
Insercioacuten de engrapadora lineal cortante a traveacutes de los orificios del tracto de la herida pulmonar penetrante
Figura 3- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales con fuga aeacuterea visible
Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales
Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
- Slide 1
- Slide 2
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
- Slide 10
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- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
The patient is transferred to the ICU for continued physiologic restoration in the third phase
Once coagulopathy hypothermia and acidosis have been corrected the patient can be returned to the operating room for definitive management of the injuries in the fourth phase
48-72 h after first surgery
COMPLICATIONS OF DAMAGE CONTROL LAPAROTOMY
1) ACS Acute Compartmental Syndrome
2) ARDS Acute Respiratory Distress of the Adult
3) MOF Multiple organ failure
4) DEATH
ABDOMINAL COMPARTMENT SYNDROME is defined as an intra-abdominal pressure of greater than 20 cm H2O with evidence of impaired organ function ie elevated peak airway pressures (gt45 cm
H2O) oliguria (lt05 mLkg per hour) or cardiovascular dysfunction
(hypotension despite adequate volume resuscitation or if a pulmonary artery catheter is present oxygen delivery index [calculated as milliliters of oxygen per minute per meter squared] of 600) Intra-abdominal pressure was measured indirectly using an indwelling Foley catheter as previously described
Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13 Damage control surgery in the abdomen an approach for the management of severe injured patientsGermanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis NNuffield Department of Surgery John Radcliffe Hospital Oxford UK Curr Opin Crit Care 2006 Aug12(4)346-50 Damage-control laparotomy Lee JC Peitzman AB Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA
ABDOMINAL COMPARTMENT SYNDROME occurred in 17 (33) of
52 Patients undergoing damage-control laparotomy and was
associated with a much higher incidence of ARDS and MOF (71 vs
31 without ACS P = 02)
More importantly our study suggests that primary fascial closure at
the termination of the initial damage-control laparotomy contributes to
the development of ACS as well as subsequent organ failure
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal ypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
Mayberry JC Mullins RJ Crass RA Trunkey DD Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure Arch Surg 1997132957-962
bull MOF Multiple organ failure
Seems to be a major source of postinjury morbidity and the leading cause of in-hospital mortality despite more than 25 years of intense investigation
Eiseman B Beart R Norton L Multiple organ failure Surg Gynecol Obstet 1977144323-326
Bauer AE Durham R Faist E Systemic inflammatory response syndrome (SIRS) multiple organ dysfunction syndrome (MODS) multiple organ failure (MOF) are we winning the battle Shock 19981079-89
The current pathophysiologic model of MOF focuses on uncontrolled systemic
hyperinflammation as a unifying concept following a variety of insults
Moore FA Moore EE Evolving concepts in the pathogenesis of postinjury multiple organ failure Surg Clin North Am 199575257-277
Goris RJ te Boekhorst TP Nuytinck JK Gimbrere JS Multiple-organ failure generalized autodestructive inflammation Arch Surg 19851201109-1115
Nuytinck HK Offermans XJ Kubat K Goris JA Whole-body inflammation in trauma patients an autopsy study Arch Surg 19881231519-1524
Examples that improve the prognosis of MOF include damage control surgery recognition of abdominal compartment syndrome lung protective ventilation
strategies and tight glucose level control
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal hypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
The Acute Respiratory Distress Syndrome Network Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome N Engl J Med 20003421301-1308
Amato MB Barbas CS Medeiros DM et al Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome N Engl J Med 1998338347-354
Van den Berghe G Wouters P Weekers F et al Intensive insulin therapy in the critically ill patients N Engl J Med 20013451359-1367
The incidence of postinjury MOF has been reported to be between 7 and 66 with an associated mortality rate between 31 and 80
Fry DE Pearlstein L Fulton RL Polk HC Jr Multiple system organ failure the role of uncontrolled infection Arch Surg 1980115136-140
Regel G Lobenhoffer P Grotz M Pape HC Lehmann U Tscherne H Treatment results of patients with multiple trauma an analysis of 3406 cases treated between 1972 and 1991 at a German level I trauma center J Trauma 19953870-78
Sauaia A Moore FA Moore EE Norris JM Lezotte DC Hamman RF Multiple organ failure can be predicted as early as 12 hours after injury J Trauma 199845291-303
Nast-Kolb D Aufmkolk M Rucholtz S Obertacke U Waydhas C Multiple organ failure still a major cause of morbidity but not mortality in blunt multiple trauma J Trauma 200151835-842 Durham RM Moran JJ Mazuski JE Shapiro MJ Baue AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
It has been suggested that MOF is disappearing owing to advances in trauma and critical care
Levine JH Durham RM Moran J Bauer A Multiple organ failure is it disappearing World J Surg 199620471-473
Recent reports have not demonstrated a consistent change in either the incidence or the mortality rate associated with postinjury MOF Some groups have reported no change in the incidence but a decreased mortality while others have reported both decreased incidence and mortality compared with historical control subjects
Durham RM Moran JJ Mazuski JE Shapiro MJ Bauer AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
Regel G Grotz M Weltner T Sturm JA Tscherne H Pattern of organ failure following severe trauma World J Surg 199620422-429
Orthopaedic Trauma
Open pelvic fractures in addition to the pelvic ring injury are associated with hemorrhage and neurological insult visceral injuries are more common and a high rate of infection is seen Mortality of open pelvic fractures historically approached 50 Control of bleeding is the most important initial measure followed by debridement and packing of open wounds
Open book- widened symphysis pubis Dislocated Rt SI joint Vallier + Jenkins In Trauma Anesthesia 2008
Type 1 fractures occur due to anterior-posterior
compressioncan cause the symphysis pubis to ldquopoprdquo open leading to pubic rami or ldquoopen
bookrdquo fractures A lateral compression fracture type 2 or vertical sheer facture (Type 3) can
also lead to severe bleeding Into the pelvis Pelvic and acetabular surgery are major surgical interventions
Figura 1- Aplicacioacuten de la engrapadora para la reseccioacuten pulmonar en cuntildea Los segmentos a resecar se limitan por medio de la aplicacioacuten de dispositivos de grapado orientados en direcciones perpendiculares tratando de mantener la mayor cantidad de tejido sano
Insercioacuten de engrapadora lineal cortante a traveacutes de los orificios del tracto de la herida pulmonar penetrante
Figura 3- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales con fuga aeacuterea visible
Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales
Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
- Slide 1
- Slide 2
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
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- Slide 31
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- Slide 33
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- Slide 35
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- Slide 37
- Slide 38
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- Slide 40
- Slide 41
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- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
Once coagulopathy hypothermia and acidosis have been corrected the patient can be returned to the operating room for definitive management of the injuries in the fourth phase
48-72 h after first surgery
COMPLICATIONS OF DAMAGE CONTROL LAPAROTOMY
1) ACS Acute Compartmental Syndrome
2) ARDS Acute Respiratory Distress of the Adult
3) MOF Multiple organ failure
4) DEATH
ABDOMINAL COMPARTMENT SYNDROME is defined as an intra-abdominal pressure of greater than 20 cm H2O with evidence of impaired organ function ie elevated peak airway pressures (gt45 cm
H2O) oliguria (lt05 mLkg per hour) or cardiovascular dysfunction
(hypotension despite adequate volume resuscitation or if a pulmonary artery catheter is present oxygen delivery index [calculated as milliliters of oxygen per minute per meter squared] of 600) Intra-abdominal pressure was measured indirectly using an indwelling Foley catheter as previously described
Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13 Damage control surgery in the abdomen an approach for the management of severe injured patientsGermanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis NNuffield Department of Surgery John Radcliffe Hospital Oxford UK Curr Opin Crit Care 2006 Aug12(4)346-50 Damage-control laparotomy Lee JC Peitzman AB Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA
ABDOMINAL COMPARTMENT SYNDROME occurred in 17 (33) of
52 Patients undergoing damage-control laparotomy and was
associated with a much higher incidence of ARDS and MOF (71 vs
31 without ACS P = 02)
More importantly our study suggests that primary fascial closure at
the termination of the initial damage-control laparotomy contributes to
the development of ACS as well as subsequent organ failure
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal ypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
Mayberry JC Mullins RJ Crass RA Trunkey DD Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure Arch Surg 1997132957-962
bull MOF Multiple organ failure
Seems to be a major source of postinjury morbidity and the leading cause of in-hospital mortality despite more than 25 years of intense investigation
Eiseman B Beart R Norton L Multiple organ failure Surg Gynecol Obstet 1977144323-326
Bauer AE Durham R Faist E Systemic inflammatory response syndrome (SIRS) multiple organ dysfunction syndrome (MODS) multiple organ failure (MOF) are we winning the battle Shock 19981079-89
The current pathophysiologic model of MOF focuses on uncontrolled systemic
hyperinflammation as a unifying concept following a variety of insults
Moore FA Moore EE Evolving concepts in the pathogenesis of postinjury multiple organ failure Surg Clin North Am 199575257-277
Goris RJ te Boekhorst TP Nuytinck JK Gimbrere JS Multiple-organ failure generalized autodestructive inflammation Arch Surg 19851201109-1115
Nuytinck HK Offermans XJ Kubat K Goris JA Whole-body inflammation in trauma patients an autopsy study Arch Surg 19881231519-1524
Examples that improve the prognosis of MOF include damage control surgery recognition of abdominal compartment syndrome lung protective ventilation
strategies and tight glucose level control
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal hypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
The Acute Respiratory Distress Syndrome Network Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome N Engl J Med 20003421301-1308
Amato MB Barbas CS Medeiros DM et al Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome N Engl J Med 1998338347-354
Van den Berghe G Wouters P Weekers F et al Intensive insulin therapy in the critically ill patients N Engl J Med 20013451359-1367
The incidence of postinjury MOF has been reported to be between 7 and 66 with an associated mortality rate between 31 and 80
Fry DE Pearlstein L Fulton RL Polk HC Jr Multiple system organ failure the role of uncontrolled infection Arch Surg 1980115136-140
Regel G Lobenhoffer P Grotz M Pape HC Lehmann U Tscherne H Treatment results of patients with multiple trauma an analysis of 3406 cases treated between 1972 and 1991 at a German level I trauma center J Trauma 19953870-78
Sauaia A Moore FA Moore EE Norris JM Lezotte DC Hamman RF Multiple organ failure can be predicted as early as 12 hours after injury J Trauma 199845291-303
Nast-Kolb D Aufmkolk M Rucholtz S Obertacke U Waydhas C Multiple organ failure still a major cause of morbidity but not mortality in blunt multiple trauma J Trauma 200151835-842 Durham RM Moran JJ Mazuski JE Shapiro MJ Baue AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
It has been suggested that MOF is disappearing owing to advances in trauma and critical care
Levine JH Durham RM Moran J Bauer A Multiple organ failure is it disappearing World J Surg 199620471-473
Recent reports have not demonstrated a consistent change in either the incidence or the mortality rate associated with postinjury MOF Some groups have reported no change in the incidence but a decreased mortality while others have reported both decreased incidence and mortality compared with historical control subjects
Durham RM Moran JJ Mazuski JE Shapiro MJ Bauer AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
Regel G Grotz M Weltner T Sturm JA Tscherne H Pattern of organ failure following severe trauma World J Surg 199620422-429
Orthopaedic Trauma
Open pelvic fractures in addition to the pelvic ring injury are associated with hemorrhage and neurological insult visceral injuries are more common and a high rate of infection is seen Mortality of open pelvic fractures historically approached 50 Control of bleeding is the most important initial measure followed by debridement and packing of open wounds
Open book- widened symphysis pubis Dislocated Rt SI joint Vallier + Jenkins In Trauma Anesthesia 2008
Type 1 fractures occur due to anterior-posterior
compressioncan cause the symphysis pubis to ldquopoprdquo open leading to pubic rami or ldquoopen
bookrdquo fractures A lateral compression fracture type 2 or vertical sheer facture (Type 3) can
also lead to severe bleeding Into the pelvis Pelvic and acetabular surgery are major surgical interventions
Figura 1- Aplicacioacuten de la engrapadora para la reseccioacuten pulmonar en cuntildea Los segmentos a resecar se limitan por medio de la aplicacioacuten de dispositivos de grapado orientados en direcciones perpendiculares tratando de mantener la mayor cantidad de tejido sano
Insercioacuten de engrapadora lineal cortante a traveacutes de los orificios del tracto de la herida pulmonar penetrante
Figura 3- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales con fuga aeacuterea visible
Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales
Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
- Slide 1
- Slide 2
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
- Slide 10
- Slide 11
- Slide 12
- Slide 13
- Slide 14
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- Slide 31
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- Slide 37
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
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- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
COMPLICATIONS OF DAMAGE CONTROL LAPAROTOMY
1) ACS Acute Compartmental Syndrome
2) ARDS Acute Respiratory Distress of the Adult
3) MOF Multiple organ failure
4) DEATH
ABDOMINAL COMPARTMENT SYNDROME is defined as an intra-abdominal pressure of greater than 20 cm H2O with evidence of impaired organ function ie elevated peak airway pressures (gt45 cm
H2O) oliguria (lt05 mLkg per hour) or cardiovascular dysfunction
(hypotension despite adequate volume resuscitation or if a pulmonary artery catheter is present oxygen delivery index [calculated as milliliters of oxygen per minute per meter squared] of 600) Intra-abdominal pressure was measured indirectly using an indwelling Foley catheter as previously described
Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13 Damage control surgery in the abdomen an approach for the management of severe injured patientsGermanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis NNuffield Department of Surgery John Radcliffe Hospital Oxford UK Curr Opin Crit Care 2006 Aug12(4)346-50 Damage-control laparotomy Lee JC Peitzman AB Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA
ABDOMINAL COMPARTMENT SYNDROME occurred in 17 (33) of
52 Patients undergoing damage-control laparotomy and was
associated with a much higher incidence of ARDS and MOF (71 vs
31 without ACS P = 02)
More importantly our study suggests that primary fascial closure at
the termination of the initial damage-control laparotomy contributes to
the development of ACS as well as subsequent organ failure
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal ypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
Mayberry JC Mullins RJ Crass RA Trunkey DD Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure Arch Surg 1997132957-962
bull MOF Multiple organ failure
Seems to be a major source of postinjury morbidity and the leading cause of in-hospital mortality despite more than 25 years of intense investigation
Eiseman B Beart R Norton L Multiple organ failure Surg Gynecol Obstet 1977144323-326
Bauer AE Durham R Faist E Systemic inflammatory response syndrome (SIRS) multiple organ dysfunction syndrome (MODS) multiple organ failure (MOF) are we winning the battle Shock 19981079-89
The current pathophysiologic model of MOF focuses on uncontrolled systemic
hyperinflammation as a unifying concept following a variety of insults
Moore FA Moore EE Evolving concepts in the pathogenesis of postinjury multiple organ failure Surg Clin North Am 199575257-277
Goris RJ te Boekhorst TP Nuytinck JK Gimbrere JS Multiple-organ failure generalized autodestructive inflammation Arch Surg 19851201109-1115
Nuytinck HK Offermans XJ Kubat K Goris JA Whole-body inflammation in trauma patients an autopsy study Arch Surg 19881231519-1524
Examples that improve the prognosis of MOF include damage control surgery recognition of abdominal compartment syndrome lung protective ventilation
strategies and tight glucose level control
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal hypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
The Acute Respiratory Distress Syndrome Network Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome N Engl J Med 20003421301-1308
Amato MB Barbas CS Medeiros DM et al Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome N Engl J Med 1998338347-354
Van den Berghe G Wouters P Weekers F et al Intensive insulin therapy in the critically ill patients N Engl J Med 20013451359-1367
The incidence of postinjury MOF has been reported to be between 7 and 66 with an associated mortality rate between 31 and 80
Fry DE Pearlstein L Fulton RL Polk HC Jr Multiple system organ failure the role of uncontrolled infection Arch Surg 1980115136-140
Regel G Lobenhoffer P Grotz M Pape HC Lehmann U Tscherne H Treatment results of patients with multiple trauma an analysis of 3406 cases treated between 1972 and 1991 at a German level I trauma center J Trauma 19953870-78
Sauaia A Moore FA Moore EE Norris JM Lezotte DC Hamman RF Multiple organ failure can be predicted as early as 12 hours after injury J Trauma 199845291-303
Nast-Kolb D Aufmkolk M Rucholtz S Obertacke U Waydhas C Multiple organ failure still a major cause of morbidity but not mortality in blunt multiple trauma J Trauma 200151835-842 Durham RM Moran JJ Mazuski JE Shapiro MJ Baue AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
It has been suggested that MOF is disappearing owing to advances in trauma and critical care
Levine JH Durham RM Moran J Bauer A Multiple organ failure is it disappearing World J Surg 199620471-473
Recent reports have not demonstrated a consistent change in either the incidence or the mortality rate associated with postinjury MOF Some groups have reported no change in the incidence but a decreased mortality while others have reported both decreased incidence and mortality compared with historical control subjects
Durham RM Moran JJ Mazuski JE Shapiro MJ Bauer AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
Regel G Grotz M Weltner T Sturm JA Tscherne H Pattern of organ failure following severe trauma World J Surg 199620422-429
Orthopaedic Trauma
Open pelvic fractures in addition to the pelvic ring injury are associated with hemorrhage and neurological insult visceral injuries are more common and a high rate of infection is seen Mortality of open pelvic fractures historically approached 50 Control of bleeding is the most important initial measure followed by debridement and packing of open wounds
Open book- widened symphysis pubis Dislocated Rt SI joint Vallier + Jenkins In Trauma Anesthesia 2008
Type 1 fractures occur due to anterior-posterior
compressioncan cause the symphysis pubis to ldquopoprdquo open leading to pubic rami or ldquoopen
bookrdquo fractures A lateral compression fracture type 2 or vertical sheer facture (Type 3) can
also lead to severe bleeding Into the pelvis Pelvic and acetabular surgery are major surgical interventions
Figura 1- Aplicacioacuten de la engrapadora para la reseccioacuten pulmonar en cuntildea Los segmentos a resecar se limitan por medio de la aplicacioacuten de dispositivos de grapado orientados en direcciones perpendiculares tratando de mantener la mayor cantidad de tejido sano
Insercioacuten de engrapadora lineal cortante a traveacutes de los orificios del tracto de la herida pulmonar penetrante
Figura 3- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales con fuga aeacuterea visible
Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales
Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
- Slide 1
- Slide 2
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
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-
ABDOMINAL COMPARTMENT SYNDROME is defined as an intra-abdominal pressure of greater than 20 cm H2O with evidence of impaired organ function ie elevated peak airway pressures (gt45 cm
H2O) oliguria (lt05 mLkg per hour) or cardiovascular dysfunction
(hypotension despite adequate volume resuscitation or if a pulmonary artery catheter is present oxygen delivery index [calculated as milliliters of oxygen per minute per meter squared] of 600) Intra-abdominal pressure was measured indirectly using an indwelling Foley catheter as previously described
Int J Surg 2008 Jun6(3)246-52 Epub 2007 May 13 Damage control surgery in the abdomen an approach for the management of severe injured patientsGermanos S Gourgiotis S Villias C Bertucci M Dimopoulos N Salemis NNuffield Department of Surgery John Radcliffe Hospital Oxford UK Curr Opin Crit Care 2006 Aug12(4)346-50 Damage-control laparotomy Lee JC Peitzman AB Department of Surgery University of Pittsburgh UPMC-Presbyterian Pittsburgh Pennsylvania 15213 USA
ABDOMINAL COMPARTMENT SYNDROME occurred in 17 (33) of
52 Patients undergoing damage-control laparotomy and was
associated with a much higher incidence of ARDS and MOF (71 vs
31 without ACS P = 02)
More importantly our study suggests that primary fascial closure at
the termination of the initial damage-control laparotomy contributes to
the development of ACS as well as subsequent organ failure
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal ypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
Mayberry JC Mullins RJ Crass RA Trunkey DD Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure Arch Surg 1997132957-962
bull MOF Multiple organ failure
Seems to be a major source of postinjury morbidity and the leading cause of in-hospital mortality despite more than 25 years of intense investigation
Eiseman B Beart R Norton L Multiple organ failure Surg Gynecol Obstet 1977144323-326
Bauer AE Durham R Faist E Systemic inflammatory response syndrome (SIRS) multiple organ dysfunction syndrome (MODS) multiple organ failure (MOF) are we winning the battle Shock 19981079-89
The current pathophysiologic model of MOF focuses on uncontrolled systemic
hyperinflammation as a unifying concept following a variety of insults
Moore FA Moore EE Evolving concepts in the pathogenesis of postinjury multiple organ failure Surg Clin North Am 199575257-277
Goris RJ te Boekhorst TP Nuytinck JK Gimbrere JS Multiple-organ failure generalized autodestructive inflammation Arch Surg 19851201109-1115
Nuytinck HK Offermans XJ Kubat K Goris JA Whole-body inflammation in trauma patients an autopsy study Arch Surg 19881231519-1524
Examples that improve the prognosis of MOF include damage control surgery recognition of abdominal compartment syndrome lung protective ventilation
strategies and tight glucose level control
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal hypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
The Acute Respiratory Distress Syndrome Network Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome N Engl J Med 20003421301-1308
Amato MB Barbas CS Medeiros DM et al Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome N Engl J Med 1998338347-354
Van den Berghe G Wouters P Weekers F et al Intensive insulin therapy in the critically ill patients N Engl J Med 20013451359-1367
The incidence of postinjury MOF has been reported to be between 7 and 66 with an associated mortality rate between 31 and 80
Fry DE Pearlstein L Fulton RL Polk HC Jr Multiple system organ failure the role of uncontrolled infection Arch Surg 1980115136-140
Regel G Lobenhoffer P Grotz M Pape HC Lehmann U Tscherne H Treatment results of patients with multiple trauma an analysis of 3406 cases treated between 1972 and 1991 at a German level I trauma center J Trauma 19953870-78
Sauaia A Moore FA Moore EE Norris JM Lezotte DC Hamman RF Multiple organ failure can be predicted as early as 12 hours after injury J Trauma 199845291-303
Nast-Kolb D Aufmkolk M Rucholtz S Obertacke U Waydhas C Multiple organ failure still a major cause of morbidity but not mortality in blunt multiple trauma J Trauma 200151835-842 Durham RM Moran JJ Mazuski JE Shapiro MJ Baue AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
It has been suggested that MOF is disappearing owing to advances in trauma and critical care
Levine JH Durham RM Moran J Bauer A Multiple organ failure is it disappearing World J Surg 199620471-473
Recent reports have not demonstrated a consistent change in either the incidence or the mortality rate associated with postinjury MOF Some groups have reported no change in the incidence but a decreased mortality while others have reported both decreased incidence and mortality compared with historical control subjects
Durham RM Moran JJ Mazuski JE Shapiro MJ Bauer AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
Regel G Grotz M Weltner T Sturm JA Tscherne H Pattern of organ failure following severe trauma World J Surg 199620422-429
Orthopaedic Trauma
Open pelvic fractures in addition to the pelvic ring injury are associated with hemorrhage and neurological insult visceral injuries are more common and a high rate of infection is seen Mortality of open pelvic fractures historically approached 50 Control of bleeding is the most important initial measure followed by debridement and packing of open wounds
Open book- widened symphysis pubis Dislocated Rt SI joint Vallier + Jenkins In Trauma Anesthesia 2008
Type 1 fractures occur due to anterior-posterior
compressioncan cause the symphysis pubis to ldquopoprdquo open leading to pubic rami or ldquoopen
bookrdquo fractures A lateral compression fracture type 2 or vertical sheer facture (Type 3) can
also lead to severe bleeding Into the pelvis Pelvic and acetabular surgery are major surgical interventions
Figura 1- Aplicacioacuten de la engrapadora para la reseccioacuten pulmonar en cuntildea Los segmentos a resecar se limitan por medio de la aplicacioacuten de dispositivos de grapado orientados en direcciones perpendiculares tratando de mantener la mayor cantidad de tejido sano
Insercioacuten de engrapadora lineal cortante a traveacutes de los orificios del tracto de la herida pulmonar penetrante
Figura 3- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales con fuga aeacuterea visible
Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales
Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
- Slide 1
- Slide 2
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
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-
ABDOMINAL COMPARTMENT SYNDROME occurred in 17 (33) of
52 Patients undergoing damage-control laparotomy and was
associated with a much higher incidence of ARDS and MOF (71 vs
31 without ACS P = 02)
More importantly our study suggests that primary fascial closure at
the termination of the initial damage-control laparotomy contributes to
the development of ACS as well as subsequent organ failure
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal ypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
Mayberry JC Mullins RJ Crass RA Trunkey DD Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure Arch Surg 1997132957-962
bull MOF Multiple organ failure
Seems to be a major source of postinjury morbidity and the leading cause of in-hospital mortality despite more than 25 years of intense investigation
Eiseman B Beart R Norton L Multiple organ failure Surg Gynecol Obstet 1977144323-326
Bauer AE Durham R Faist E Systemic inflammatory response syndrome (SIRS) multiple organ dysfunction syndrome (MODS) multiple organ failure (MOF) are we winning the battle Shock 19981079-89
The current pathophysiologic model of MOF focuses on uncontrolled systemic
hyperinflammation as a unifying concept following a variety of insults
Moore FA Moore EE Evolving concepts in the pathogenesis of postinjury multiple organ failure Surg Clin North Am 199575257-277
Goris RJ te Boekhorst TP Nuytinck JK Gimbrere JS Multiple-organ failure generalized autodestructive inflammation Arch Surg 19851201109-1115
Nuytinck HK Offermans XJ Kubat K Goris JA Whole-body inflammation in trauma patients an autopsy study Arch Surg 19881231519-1524
Examples that improve the prognosis of MOF include damage control surgery recognition of abdominal compartment syndrome lung protective ventilation
strategies and tight glucose level control
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal hypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
The Acute Respiratory Distress Syndrome Network Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome N Engl J Med 20003421301-1308
Amato MB Barbas CS Medeiros DM et al Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome N Engl J Med 1998338347-354
Van den Berghe G Wouters P Weekers F et al Intensive insulin therapy in the critically ill patients N Engl J Med 20013451359-1367
The incidence of postinjury MOF has been reported to be between 7 and 66 with an associated mortality rate between 31 and 80
Fry DE Pearlstein L Fulton RL Polk HC Jr Multiple system organ failure the role of uncontrolled infection Arch Surg 1980115136-140
Regel G Lobenhoffer P Grotz M Pape HC Lehmann U Tscherne H Treatment results of patients with multiple trauma an analysis of 3406 cases treated between 1972 and 1991 at a German level I trauma center J Trauma 19953870-78
Sauaia A Moore FA Moore EE Norris JM Lezotte DC Hamman RF Multiple organ failure can be predicted as early as 12 hours after injury J Trauma 199845291-303
Nast-Kolb D Aufmkolk M Rucholtz S Obertacke U Waydhas C Multiple organ failure still a major cause of morbidity but not mortality in blunt multiple trauma J Trauma 200151835-842 Durham RM Moran JJ Mazuski JE Shapiro MJ Baue AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
It has been suggested that MOF is disappearing owing to advances in trauma and critical care
Levine JH Durham RM Moran J Bauer A Multiple organ failure is it disappearing World J Surg 199620471-473
Recent reports have not demonstrated a consistent change in either the incidence or the mortality rate associated with postinjury MOF Some groups have reported no change in the incidence but a decreased mortality while others have reported both decreased incidence and mortality compared with historical control subjects
Durham RM Moran JJ Mazuski JE Shapiro MJ Bauer AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
Regel G Grotz M Weltner T Sturm JA Tscherne H Pattern of organ failure following severe trauma World J Surg 199620422-429
Orthopaedic Trauma
Open pelvic fractures in addition to the pelvic ring injury are associated with hemorrhage and neurological insult visceral injuries are more common and a high rate of infection is seen Mortality of open pelvic fractures historically approached 50 Control of bleeding is the most important initial measure followed by debridement and packing of open wounds
Open book- widened symphysis pubis Dislocated Rt SI joint Vallier + Jenkins In Trauma Anesthesia 2008
Type 1 fractures occur due to anterior-posterior
compressioncan cause the symphysis pubis to ldquopoprdquo open leading to pubic rami or ldquoopen
bookrdquo fractures A lateral compression fracture type 2 or vertical sheer facture (Type 3) can
also lead to severe bleeding Into the pelvis Pelvic and acetabular surgery are major surgical interventions
Figura 1- Aplicacioacuten de la engrapadora para la reseccioacuten pulmonar en cuntildea Los segmentos a resecar se limitan por medio de la aplicacioacuten de dispositivos de grapado orientados en direcciones perpendiculares tratando de mantener la mayor cantidad de tejido sano
Insercioacuten de engrapadora lineal cortante a traveacutes de los orificios del tracto de la herida pulmonar penetrante
Figura 3- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales con fuga aeacuterea visible
Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales
Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
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- Slide 2
- Slide 3
- Slide 4
- Slide 5
- Slide 6
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- Slide 53
- Slide 54
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- Slide 57
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- Slide 59
-
bull MOF Multiple organ failure
Seems to be a major source of postinjury morbidity and the leading cause of in-hospital mortality despite more than 25 years of intense investigation
Eiseman B Beart R Norton L Multiple organ failure Surg Gynecol Obstet 1977144323-326
Bauer AE Durham R Faist E Systemic inflammatory response syndrome (SIRS) multiple organ dysfunction syndrome (MODS) multiple organ failure (MOF) are we winning the battle Shock 19981079-89
The current pathophysiologic model of MOF focuses on uncontrolled systemic
hyperinflammation as a unifying concept following a variety of insults
Moore FA Moore EE Evolving concepts in the pathogenesis of postinjury multiple organ failure Surg Clin North Am 199575257-277
Goris RJ te Boekhorst TP Nuytinck JK Gimbrere JS Multiple-organ failure generalized autodestructive inflammation Arch Surg 19851201109-1115
Nuytinck HK Offermans XJ Kubat K Goris JA Whole-body inflammation in trauma patients an autopsy study Arch Surg 19881231519-1524
Examples that improve the prognosis of MOF include damage control surgery recognition of abdominal compartment syndrome lung protective ventilation
strategies and tight glucose level control
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal hypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
The Acute Respiratory Distress Syndrome Network Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome N Engl J Med 20003421301-1308
Amato MB Barbas CS Medeiros DM et al Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome N Engl J Med 1998338347-354
Van den Berghe G Wouters P Weekers F et al Intensive insulin therapy in the critically ill patients N Engl J Med 20013451359-1367
The incidence of postinjury MOF has been reported to be between 7 and 66 with an associated mortality rate between 31 and 80
Fry DE Pearlstein L Fulton RL Polk HC Jr Multiple system organ failure the role of uncontrolled infection Arch Surg 1980115136-140
Regel G Lobenhoffer P Grotz M Pape HC Lehmann U Tscherne H Treatment results of patients with multiple trauma an analysis of 3406 cases treated between 1972 and 1991 at a German level I trauma center J Trauma 19953870-78
Sauaia A Moore FA Moore EE Norris JM Lezotte DC Hamman RF Multiple organ failure can be predicted as early as 12 hours after injury J Trauma 199845291-303
Nast-Kolb D Aufmkolk M Rucholtz S Obertacke U Waydhas C Multiple organ failure still a major cause of morbidity but not mortality in blunt multiple trauma J Trauma 200151835-842 Durham RM Moran JJ Mazuski JE Shapiro MJ Baue AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
It has been suggested that MOF is disappearing owing to advances in trauma and critical care
Levine JH Durham RM Moran J Bauer A Multiple organ failure is it disappearing World J Surg 199620471-473
Recent reports have not demonstrated a consistent change in either the incidence or the mortality rate associated with postinjury MOF Some groups have reported no change in the incidence but a decreased mortality while others have reported both decreased incidence and mortality compared with historical control subjects
Durham RM Moran JJ Mazuski JE Shapiro MJ Bauer AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
Regel G Grotz M Weltner T Sturm JA Tscherne H Pattern of organ failure following severe trauma World J Surg 199620422-429
Orthopaedic Trauma
Open pelvic fractures in addition to the pelvic ring injury are associated with hemorrhage and neurological insult visceral injuries are more common and a high rate of infection is seen Mortality of open pelvic fractures historically approached 50 Control of bleeding is the most important initial measure followed by debridement and packing of open wounds
Open book- widened symphysis pubis Dislocated Rt SI joint Vallier + Jenkins In Trauma Anesthesia 2008
Type 1 fractures occur due to anterior-posterior
compressioncan cause the symphysis pubis to ldquopoprdquo open leading to pubic rami or ldquoopen
bookrdquo fractures A lateral compression fracture type 2 or vertical sheer facture (Type 3) can
also lead to severe bleeding Into the pelvis Pelvic and acetabular surgery are major surgical interventions
Figura 1- Aplicacioacuten de la engrapadora para la reseccioacuten pulmonar en cuntildea Los segmentos a resecar se limitan por medio de la aplicacioacuten de dispositivos de grapado orientados en direcciones perpendiculares tratando de mantener la mayor cantidad de tejido sano
Insercioacuten de engrapadora lineal cortante a traveacutes de los orificios del tracto de la herida pulmonar penetrante
Figura 3- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales con fuga aeacuterea visible
Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales
Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
- Slide 1
- Slide 2
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
- Slide 10
- Slide 11
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- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
Examples that improve the prognosis of MOF include damage control surgery recognition of abdominal compartment syndrome lung protective ventilation
strategies and tight glucose level control
Ivatury RR Porter JM Simon RJ Islam S John R Stahl WM Intra-abdominal hypertension after life-threatening penetrating abdominal trauma prophylaxis incidence and clinical relevance to gastric mucosal pH and abdominal compartment syndrome J Trauma 1998441016-1023
The Acute Respiratory Distress Syndrome Network Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome N Engl J Med 20003421301-1308
Amato MB Barbas CS Medeiros DM et al Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome N Engl J Med 1998338347-354
Van den Berghe G Wouters P Weekers F et al Intensive insulin therapy in the critically ill patients N Engl J Med 20013451359-1367
The incidence of postinjury MOF has been reported to be between 7 and 66 with an associated mortality rate between 31 and 80
Fry DE Pearlstein L Fulton RL Polk HC Jr Multiple system organ failure the role of uncontrolled infection Arch Surg 1980115136-140
Regel G Lobenhoffer P Grotz M Pape HC Lehmann U Tscherne H Treatment results of patients with multiple trauma an analysis of 3406 cases treated between 1972 and 1991 at a German level I trauma center J Trauma 19953870-78
Sauaia A Moore FA Moore EE Norris JM Lezotte DC Hamman RF Multiple organ failure can be predicted as early as 12 hours after injury J Trauma 199845291-303
Nast-Kolb D Aufmkolk M Rucholtz S Obertacke U Waydhas C Multiple organ failure still a major cause of morbidity but not mortality in blunt multiple trauma J Trauma 200151835-842 Durham RM Moran JJ Mazuski JE Shapiro MJ Baue AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
It has been suggested that MOF is disappearing owing to advances in trauma and critical care
Levine JH Durham RM Moran J Bauer A Multiple organ failure is it disappearing World J Surg 199620471-473
Recent reports have not demonstrated a consistent change in either the incidence or the mortality rate associated with postinjury MOF Some groups have reported no change in the incidence but a decreased mortality while others have reported both decreased incidence and mortality compared with historical control subjects
Durham RM Moran JJ Mazuski JE Shapiro MJ Bauer AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
Regel G Grotz M Weltner T Sturm JA Tscherne H Pattern of organ failure following severe trauma World J Surg 199620422-429
Orthopaedic Trauma
Open pelvic fractures in addition to the pelvic ring injury are associated with hemorrhage and neurological insult visceral injuries are more common and a high rate of infection is seen Mortality of open pelvic fractures historically approached 50 Control of bleeding is the most important initial measure followed by debridement and packing of open wounds
Open book- widened symphysis pubis Dislocated Rt SI joint Vallier + Jenkins In Trauma Anesthesia 2008
Type 1 fractures occur due to anterior-posterior
compressioncan cause the symphysis pubis to ldquopoprdquo open leading to pubic rami or ldquoopen
bookrdquo fractures A lateral compression fracture type 2 or vertical sheer facture (Type 3) can
also lead to severe bleeding Into the pelvis Pelvic and acetabular surgery are major surgical interventions
Figura 1- Aplicacioacuten de la engrapadora para la reseccioacuten pulmonar en cuntildea Los segmentos a resecar se limitan por medio de la aplicacioacuten de dispositivos de grapado orientados en direcciones perpendiculares tratando de mantener la mayor cantidad de tejido sano
Insercioacuten de engrapadora lineal cortante a traveacutes de los orificios del tracto de la herida pulmonar penetrante
Figura 3- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales con fuga aeacuterea visible
Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales
Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
- Slide 1
- Slide 2
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
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- Slide 53
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- Slide 57
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- Slide 59
-
The incidence of postinjury MOF has been reported to be between 7 and 66 with an associated mortality rate between 31 and 80
Fry DE Pearlstein L Fulton RL Polk HC Jr Multiple system organ failure the role of uncontrolled infection Arch Surg 1980115136-140
Regel G Lobenhoffer P Grotz M Pape HC Lehmann U Tscherne H Treatment results of patients with multiple trauma an analysis of 3406 cases treated between 1972 and 1991 at a German level I trauma center J Trauma 19953870-78
Sauaia A Moore FA Moore EE Norris JM Lezotte DC Hamman RF Multiple organ failure can be predicted as early as 12 hours after injury J Trauma 199845291-303
Nast-Kolb D Aufmkolk M Rucholtz S Obertacke U Waydhas C Multiple organ failure still a major cause of morbidity but not mortality in blunt multiple trauma J Trauma 200151835-842 Durham RM Moran JJ Mazuski JE Shapiro MJ Baue AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
It has been suggested that MOF is disappearing owing to advances in trauma and critical care
Levine JH Durham RM Moran J Bauer A Multiple organ failure is it disappearing World J Surg 199620471-473
Recent reports have not demonstrated a consistent change in either the incidence or the mortality rate associated with postinjury MOF Some groups have reported no change in the incidence but a decreased mortality while others have reported both decreased incidence and mortality compared with historical control subjects
Durham RM Moran JJ Mazuski JE Shapiro MJ Bauer AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
Regel G Grotz M Weltner T Sturm JA Tscherne H Pattern of organ failure following severe trauma World J Surg 199620422-429
Orthopaedic Trauma
Open pelvic fractures in addition to the pelvic ring injury are associated with hemorrhage and neurological insult visceral injuries are more common and a high rate of infection is seen Mortality of open pelvic fractures historically approached 50 Control of bleeding is the most important initial measure followed by debridement and packing of open wounds
Open book- widened symphysis pubis Dislocated Rt SI joint Vallier + Jenkins In Trauma Anesthesia 2008
Type 1 fractures occur due to anterior-posterior
compressioncan cause the symphysis pubis to ldquopoprdquo open leading to pubic rami or ldquoopen
bookrdquo fractures A lateral compression fracture type 2 or vertical sheer facture (Type 3) can
also lead to severe bleeding Into the pelvis Pelvic and acetabular surgery are major surgical interventions
Figura 1- Aplicacioacuten de la engrapadora para la reseccioacuten pulmonar en cuntildea Los segmentos a resecar se limitan por medio de la aplicacioacuten de dispositivos de grapado orientados en direcciones perpendiculares tratando de mantener la mayor cantidad de tejido sano
Insercioacuten de engrapadora lineal cortante a traveacutes de los orificios del tracto de la herida pulmonar penetrante
Figura 3- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales con fuga aeacuterea visible
Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales
Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
- Slide 1
- Slide 2
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
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- Slide 50
- Slide 51
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
It has been suggested that MOF is disappearing owing to advances in trauma and critical care
Levine JH Durham RM Moran J Bauer A Multiple organ failure is it disappearing World J Surg 199620471-473
Recent reports have not demonstrated a consistent change in either the incidence or the mortality rate associated with postinjury MOF Some groups have reported no change in the incidence but a decreased mortality while others have reported both decreased incidence and mortality compared with historical control subjects
Durham RM Moran JJ Mazuski JE Shapiro MJ Bauer AE Flint LM Multiple organ failure in trauma patients J Trauma 200355608-616
Regel G Grotz M Weltner T Sturm JA Tscherne H Pattern of organ failure following severe trauma World J Surg 199620422-429
Orthopaedic Trauma
Open pelvic fractures in addition to the pelvic ring injury are associated with hemorrhage and neurological insult visceral injuries are more common and a high rate of infection is seen Mortality of open pelvic fractures historically approached 50 Control of bleeding is the most important initial measure followed by debridement and packing of open wounds
Open book- widened symphysis pubis Dislocated Rt SI joint Vallier + Jenkins In Trauma Anesthesia 2008
Type 1 fractures occur due to anterior-posterior
compressioncan cause the symphysis pubis to ldquopoprdquo open leading to pubic rami or ldquoopen
bookrdquo fractures A lateral compression fracture type 2 or vertical sheer facture (Type 3) can
also lead to severe bleeding Into the pelvis Pelvic and acetabular surgery are major surgical interventions
Figura 1- Aplicacioacuten de la engrapadora para la reseccioacuten pulmonar en cuntildea Los segmentos a resecar se limitan por medio de la aplicacioacuten de dispositivos de grapado orientados en direcciones perpendiculares tratando de mantener la mayor cantidad de tejido sano
Insercioacuten de engrapadora lineal cortante a traveacutes de los orificios del tracto de la herida pulmonar penetrante
Figura 3- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales con fuga aeacuterea visible
Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales
Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
- Slide 1
- Slide 2
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
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- Slide 53
- Slide 54
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-
Orthopaedic Trauma
Open pelvic fractures in addition to the pelvic ring injury are associated with hemorrhage and neurological insult visceral injuries are more common and a high rate of infection is seen Mortality of open pelvic fractures historically approached 50 Control of bleeding is the most important initial measure followed by debridement and packing of open wounds
Open book- widened symphysis pubis Dislocated Rt SI joint Vallier + Jenkins In Trauma Anesthesia 2008
Type 1 fractures occur due to anterior-posterior
compressioncan cause the symphysis pubis to ldquopoprdquo open leading to pubic rami or ldquoopen
bookrdquo fractures A lateral compression fracture type 2 or vertical sheer facture (Type 3) can
also lead to severe bleeding Into the pelvis Pelvic and acetabular surgery are major surgical interventions
Figura 1- Aplicacioacuten de la engrapadora para la reseccioacuten pulmonar en cuntildea Los segmentos a resecar se limitan por medio de la aplicacioacuten de dispositivos de grapado orientados en direcciones perpendiculares tratando de mantener la mayor cantidad de tejido sano
Insercioacuten de engrapadora lineal cortante a traveacutes de los orificios del tracto de la herida pulmonar penetrante
Figura 3- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales con fuga aeacuterea visible
Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales
Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
- Slide 1
- Slide 2
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
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-
Open pelvic fractures in addition to the pelvic ring injury are associated with hemorrhage and neurological insult visceral injuries are more common and a high rate of infection is seen Mortality of open pelvic fractures historically approached 50 Control of bleeding is the most important initial measure followed by debridement and packing of open wounds
Open book- widened symphysis pubis Dislocated Rt SI joint Vallier + Jenkins In Trauma Anesthesia 2008
Type 1 fractures occur due to anterior-posterior
compressioncan cause the symphysis pubis to ldquopoprdquo open leading to pubic rami or ldquoopen
bookrdquo fractures A lateral compression fracture type 2 or vertical sheer facture (Type 3) can
also lead to severe bleeding Into the pelvis Pelvic and acetabular surgery are major surgical interventions
Figura 1- Aplicacioacuten de la engrapadora para la reseccioacuten pulmonar en cuntildea Los segmentos a resecar se limitan por medio de la aplicacioacuten de dispositivos de grapado orientados en direcciones perpendiculares tratando de mantener la mayor cantidad de tejido sano
Insercioacuten de engrapadora lineal cortante a traveacutes de los orificios del tracto de la herida pulmonar penetrante
Figura 3- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales con fuga aeacuterea visible
Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales
Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
- Slide 1
- Slide 2
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
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-
Figura 1- Aplicacioacuten de la engrapadora para la reseccioacuten pulmonar en cuntildea Los segmentos a resecar se limitan por medio de la aplicacioacuten de dispositivos de grapado orientados en direcciones perpendiculares tratando de mantener la mayor cantidad de tejido sano
Insercioacuten de engrapadora lineal cortante a traveacutes de los orificios del tracto de la herida pulmonar penetrante
Figura 3- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales con fuga aeacuterea visible
Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales
Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
- Slide 1
- Slide 2
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
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- Slide 59
-
Figura 3- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales con fuga aeacuterea visible
Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y viacuteas aeacutereas distales
Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
- Slide 1
- Slide 2
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
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Aplicacioacuten de un DGQ lineal en el hilio pulmonar durante una Toracotomiacutea en el Saloacuten de Operaciones El pulmoacuten derecho se retrajo cefaacutelicamente de forma manual
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal tras el grapado y reseccioacuten del asa
Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
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Figura 6- Fotografiacutea del mismo paciente en donde se observa la liacutenea de grapas en el hilio pulmonar derecho
Figura 7- Aplicacioacuten de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado El tracto gastrointestinal se dejoacute en discontinuidad
Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
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Aplicacioacuten de la proacutetesis de la pared abdominal (bolsa plaacutestica de solucioacuten intravenosa) aseguraacutendola a la piel con engrapadoras apropiadas
Grapa metaacutelica aplicada con Ligaclip MCA Multiple Clip Applier (Ethicon Endosurgery Somerville NJ US) en un vaso sanguiacuteneo individual en el interior del pareacutenquima hepaacutetico durante una teacutecnica de CCD
Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
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Trauma team training is an invaluable part of trauma care in any trauma organitation
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However some specific surgical procedures need to be taught either in real situations or on corpses
Clinical research is an important factor in improving survival after critical incidences however it cannot stand alone A new concept Formula of Survival has emphasised the importance of education and implementation of new knowledge into clinical practise Therefore education and implementation have been a focus for developing our trauma organisation
LETacuteS TAKE A DRINK IN VALENCIA
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LETacuteS TAKE A DRINK IN VALENCIA
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