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Surgery
Prof. Marius Keel, MD, FACS
General and Trauma Surgeon
Consultant for Pelvic and Spinal Surgery
Department of Orthopaedic Surgery
Bern, Switzerland
Damage Control
SurgeryDamage Control
SurgeryWarum, Wann und Wie ?
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Damage Control - Schadensbegrenzung
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Warum, Wann und Wie ?
58
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Management und operative Akutversorgung des Polytraumas
Pathophysiology
Damage Control
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Polytrauma
> Severity of injuries (ISS ≥17 pts.)
> Physiological status
Hypothermia
Acidosis
Coagulopathy
Lethal Triad
> Host defense
Keel et al. n=1191, 1.96-9.04; ISS≥17pts.
76%
25%
60%
32%
23%
58%
> Injury pattern
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„Killers“ in Polytrauma
> Head injury (66%)
Keel et al. n=1191, 1.96-9.04; ISS≥17pts.
Coagulopathy- Dilution
- Consumption
Massive
transfusion
≥ 10 U PRBCs in
first 24 hrs
Ongoing bleeding
> Sepsis, MOF (13%)
> Hemorrhagic shock (21%)
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35.5Hypothermia°celsius
Acidosis lactate mmol/l
Coagulopathy prothrombin time %
2.8
83
35.3
3.5
74
34.2
6.3
57
Lethal Triad
Mortality (36%): 28% 33% 67%
Hemorrhagic Shock and Mortality
I<750ml
-
-
n = 630
53%
II750-1500ml
>100/min.
-
n = 368
31%
III/IV>1500/2000ml
>120/min.
<90mmHg syst.
n = 193
16%
Keel et al. n=1191, 1.96-9.04; ISS≥17pts.
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Primary survey
X-ray (thorax, pelvis)
FAST
Multislice CT ?
Resuscitation:
Preservation of
perfusion and
oxygenation
Vital functions?
Response?Life saving
surgery_
„in extremis“
Keel M, Labler L, Trentz O.
Eur J Trauma 2005; 31:212
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1. Surgical approach to airway for imminent asphyxia
3. Surgical control of hemorrhage
Pleural cavity
Peritoneal cavity
Pelvic fracture
Central amputation
Components of Life Saving Surgery
2. Decompression of cavities
Tension pneumothorax
Cardiac tamponade
Acute EDH
Keel, Labler, Trentz. Eur J Trauma Emerg Surg 2005; 31:212
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-1030
-140/20 mmHg
-140 /min.
-Lactate 13 mmol/L
-Hb 10 g/dL
-1000 work accident
-Scoop and run
-OP 1040-1150
-120/15 mmHg
-140 /min.
-Cardiac arrest –
open cardiac massage
-Aortic clamping
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Emergency Department Thoracotomy
Soreide et al. Scand J Surg 2007;96:4-10
Cothren et Moore. World J Emerg Surg 2006
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blunt penetrating Total
EDT 37(32.5%) 8(7.0%) 45 (39.5%)
ET (OR, ICU) 41(35.9%) 28(24.6%) 69 (60.5%)
78 (68.4%) 36 (31.6%) 114
Gun shot/Stab - 12 (33.3%)/24 (66.6%) -
Age 39.6 41.5 40.2
Male : Female 76% : 24% 78% : 22% 76% : 24%
Mortality EDT/ET 94.6% / 61% 25% / 11% 82% / 41%
8
12
3
12
5
7
9
17
1415
12
0
2
4
6
8
10
12
14
16
18
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
EDT+ET in 11 y
Division of Trauma Surgery
University Hospital Zürich
Switzerland
Labler, Trentz, Keel
[n]
114 Resuscitative Thoracotomy in 11y
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Outcome after Emergency Department Thoracotomy (EDT)
Soreide et al. Scand J Surg 2007;96:4-10
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Case - Basic Imaging
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Case - C-Clamp and Angiography
22:30Day 0 - 21:40
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Day 1 - 00:26
Case - Pan-CT-Scan
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> Intraperitoneal
hematoma
> Retroperitoneal
hematoma
> Scrotal
hematoma
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Case - Retrograde Uretrocystography and Scrotal Decompression
Day 1 - 10:25
? > Involvement of urologists
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Case - Explorative Laparotomy
Day 3
4 quadrant peritonitis
Mesenteric injuries of small bowel (necrosis,
perforations) and sigma
Intra- and extraperitoneal bladder rupture
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Case - SigmoidostomyExtraperitoneal Approaches for Pelvic Stabilization
> Initial ongoing bleeding after angiography
> Missed intraabdominal lesions (small
bowel, sigma, bladder)
> Unnecessary scrotal decompression
> Abdominal sepsis
> Open abdomen with abdominal wall hernia
> Deep veneous thrombosis
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Priorities of Acute Treatment
1. Shock treatment
2. Control of hemorrhage
3. Treatment of coagulopathy
Hypothermia
Acidosis
Coagulopathy
Lethal Triad
4. Prevention of septic
complications
5. Organ-/limb saving
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Multiple Organ Failure after Life Saving Surgery
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Posttraumatic CHAOS
> Cardiovascular shock
> Homeostasis
> Apoptosis
> Organ dysfunctions
> Immune Suppression
Bone. Crit Care Med 1996; 24:1125
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Pathophysiological Cascade
Endothelial/Parenchymal Cellular Damage
MODS/MOV
Neuroendocrine Reaction
Pain, Fear, Stress
Complement System Leucocytes-Endothelial-Interaction
PMN -„Respiratory
burst“
Coagulation Cascade
Acute Phase Reaction
Metabolic Disorder Kallikrein-Kinin-System
SIRS
AgTLymphocyte
Antigen Presentation
Antigen ToxinsTissue
Damage
Macrophage
TNF-a, IL-1b, IL-6, IL-8, IL-12, IL-18, MMF, HMG-1,
G-CSF, GM-CSF, PGE2, LTB4, TXA2, PAF
TH1: IL-2, IFN-g, TNF-b
Fractures BacteriaHypoxia/Hypotension
Keel, Trentz. Injury 2005; 36:691
CARS
Immuno-suppression
Infection
TH2: IL-4, IL-10, IL-13, TGF-b
Organ/Soft Tissue Injuries
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Hemorrhagic Shock and Morbidity
100
80
60
40
20
0
% infe
cte
d/n
on-infe
cte
d p
atie
nts
infected noninfected
Hemorrhagic shock class
I II III IV
% p
atie
nts
with
SIR
S / s
ep
sis
100
80
60
40
20
0
no SIRSSIRS 3/4sepsis SIRS 2
I II III IVHemorrhagic shock class
> Inclusion: ISS ≥17 pts., survival >72 hrs
> N=972 (age: 40.2 y; ISS: 31.9 pts.; late mortality: 10.5%; blunt trauma: 91.4%)
> Hemorrhagic shock: I (n=582) – II (n=309) – III (n=56) – IV (n=25)
Lustenberger et al. Eur J Trauma Emerg Surg 2009
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27
Multiple Organ Dysfunction
Syndrome (MODS)
Host Defense Response
- reversible -
„Two Hit“ – Model Keel, Trentz. Injury 2005;36:691
Moore et al. J Trauma 1996;40:501
First Hits
-Hypoxia
-Hypotension
-Organ injuries
-Soft tissue injuries
-Fractures
Systemic Inflammatory
Response Syndrome (SIRS)
-Temperature
-Pulse
-Breathing
-Leukocytes
Crit Care Med
1992;20:864
Multiple Organ Failure (MOF)
Host Defense Failure Disease - irreversible -+Bacteria
Sepsis
Second Hits
Endogen (antigenic): - Hypoxia
- Hypotension, Azidosis
- Ischemia/Reperfusion
- Cellular detritus
- Contamination/Infection
Exogen (interventional): - Surgery with blood loss,
Tissue damage, Hypothermia
- Neglected Trauma
- Missed Injuries
- Massive transfusions
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Damage Control Concept
Stop the bleeding –
Life Saving Surgery
Damage Control Surgery (DCO)
> Surgical control of hemorrhage
> Angiographic control of hemorrhage (Transcatheter arterial embolisation (TAE))
> Massive transfusion protocols (MTPs)
> Correction of coagulopathy
> Correction of hypothermia
Mitigate the lethal triad –
Damage Control Resuscitation
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Damage Control – History – US Navy
> …keeping afloat a badly damaged ship by procedures tolimit flooding, stabilize the vessel, isolate fires andexplosions and avoid their spreading…
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History: DC – DCO
> Pringle-maneuver Pringle. Ann Surg. 1908; 48:541
> Intra-abdominal packing Feliciano, et al. J Trauma. 1981; 21:285
> Damage Control as approach Rotondo, et al. J Trauma. 1993; 35:375
> Early packing – outcome Garrison, et al. J Trauma. 1996; 40:923
> Timing of fracture treatment – DCO (Damage Control Orthopaedic Surgery) Pape, et al. Am J Surg. 2002; 183:622
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Trauma – Care
Primary survey
X-ray (thorax, pelvis)
FAST
Multislice CT ?
Resuscitation:
Preservation of
perfusion and
oxygenation
Vital functions?
Response?
Early total
care+
Intensive
care unit
Day-1-
surgery
_„borderline“
Keel, Labler, Trentz.
Eur J Trauma 2005; 31:212
Physiologic
balance?
Scoring?
Ressources?
Secondary survey
X-ray (extremities)
Multislice CT
+
„responder“
?„transient
responder“
Damage control:
• Preemptive intervention
Life saving
surgery
_„in extremis“
Damage control:
• Preemptive intervention
• „Bail-out“ procedure
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Case - Damage Control Surgery
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-OP-time: 2:45
-Lactate: 2,1 mmol/L (initial: 3.2)
-Voluven 2200 mL; RL 8000 mL
-No RBC, FFP, Tc
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Suicide jump 5th floor
-1135
-105/60
mmHg
-145/min
-Lac 5.7
mmol/l
-Hb 8.2
1030
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Priorities ?
Techniques?
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Day 0
-OP time 5:45 hrs
-7 RBC
-cellsaver 680 ml
-8 FFP
-11.2 l ringer lactate
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48 hrs
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1. Bleeding Control
“Open chimney”
Abbdominal/liver packing
Pringle maneuver
External fixation and
pelvic packing
or embolization
Repair
Vascular
exclusionResection
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Source of Abdominal Bleeding
> Retroperitoneal bleeding (pelvis)
• Prevesical venous plexus
• Presacral venous plexus
• Fracture
• Small arteries: obturator/pudendal/gluteal
• Large–bore vessels
> Intraperitoneal bleeding (pelvis)• Positive FAST in 39% - 97% intraperitoneal lesion
• Solid organ lesions (liver 10%, spleen 6%) Ruchholtz, et al. J
Trauma 2004;57:278
Demetriades, et al. J Am Col Surg 2002;195:1
Grotz, et al. Injury 2006;37:642
Kataoka, et al. J Trauma 2005;58:704
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> Multislice CT
> Retrograde
cystography
(intraop or preop)
> Explorative
laparotomy
2a. Reduction of Contamination (Diagnostics)
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2a. Reduction of Contamination (Treatment)
> Treatment of hollow organ injuries:
Intraperitoneal lesions and unstable pelvic fracture: 31%
Demetriades et al. JACS 2002;195:1
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2a. Reduction of Contamination (Treatment)
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2b. Reduction of Contamination
> Débridement of open fractures
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3. Decompression of Compartment Syndrome
> Imminent
> Manifest
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4. Resection of Avital Tissue
Labler et al. Eur J Trauma Emerg Surg 2008
> Débridement of Morel Lavallé lesion
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5. Fixation of Skeletal Instabilities
> Temporary fixation: External or internal fixators (LCP ?)
> Definitive fixation: Plate, Screws
> Reduction of trauma load
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Risk Factors for Early Mortality after Damage Control Surgery
Variable Odds Ratio (95% CI) p Value
INR >1.2 10.64 (1.32 - 83.33) 0.026
Base Deficit >3 mmol/L 4.85 (1.10 - 23.81) 0.040
AIS Head ≥3 4.27 (1.55 - 11.76) 0.005
Body Temperature <35°C 3.68 (1.15 - 11.76) 0.029
Lactate >6 mmol/L 2.96 (1.00 - 9.09) 0.050
Hemoglobin <7 g/dL 2.76 (1.02 - 7.46) 0.045
Frischknecht et al. 2010 (submitted)
> DC procedures in 319 pat. (age: 39.3 y; ISS: 36.6 pts.; SBP <90
mm Hg: 8.7%)
> External fixator: C-clamp (10%), external fixator pelvis (2.5%),
external fixator extremities (60.5%)
> Packing: chest (4.7%), intraabdominal 25.7%), retroperitoneal (6.9%)
> Early mortality: 52/319 (16.3%)
> Late mortality: 22/267 (8.2%)
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All patients
(n=50)
Early survivors
(n=34)
Non-survivors
(n=16)p-value
Hemoglobin (g/dL) at
admission, mean ± SD7.4 ± 3.1 8.6 ± 2.9 4.9 ± 2.0 <0.001
Hematocrit (%) at
admission22.2 ± 9.1 25.6 ± 8.4 15.0 ± 6.0 <0.001
Prothrombin time (%) 55.5 ± 26.6 66.5 ± 23.4 34.1 ± 18.5 <0.001
SBP (mm Hg) at admission 109.5 ± 29.8 117.3 ± 25.2 90.4 ± 32.1 0.002
HR at admission 104.2 ± 21.0 100.2 ± 17.5 110.4 ± 27.7 0.02
Crystalloid solution
administration from injury
until 1 h after admission (L)
2.9 ± 1.9 2.7 ± 1.5 3.4 ± 2.4 0.42
Colloid solution
administration from injury
until 1 h after admission (L)
2.6 ± 1.8 2.1 ± 1.5 3.7 ± 1.8 0.001
PRBC administration within
1 h after admission (Units)4.7 ± 5.4 2.6 ± 3.9 8.5 ± 5.9 <0.001
FFP administration within 1
h after admission (Units)1.1 ± 1.9 0.8 ± 1.6 1.6 ± 2.3 0.20
All patients
(n=50)
Early survivors
(n=34)
Non-survivors
(n=16)p-value
Type B 16.0% (8) 8.8% (3) 31.3% (5) 0.09
B1 12.0% (6) 2.9% (1) 31.1% (5) 0.01
B2 4.0% (2) 5.9% (2) 0% (0) 1.00
Type C 84.0% (42) 91.2% (31) 68.8% (11) 0.09
C1 44.0% (22) 47.1% (16) 37.5% (6) 0.56
C2 4.0% (2) 2.9% (1) 6.3% (1) 0.54
C3 36.0% (18) 41.2% (14) 25.0% (4) 0.35
Eur J Trauma Emerg Surg 2009
Characteristics
Early
Survivors
(n=34)
Non-
Survivors
(n=16)
All
(n=50)
Laparotomy 26 (77%) 14 (88%)34
(77%)
Cross-clamping
Aorta2 (6%) 8 (50%)
10
(20%)
Pelvic packing 23 (68%) 12 (75%)35
(70%)
Thoracotomy 0 7 (44%) 7 (14%)
Mortality4 (12%):
MOF 3,
head injury 1
16: hemorrhage
13, head injury
3
20
(40%)
Time to C-clamp (min)
39.5 ± 2.2
Days till definitive pelvic stabilization
3.5 ±0.5
Age: 45 y
m:w=26:24
ISS: 42 pts.
12 years
Shock - Monitoring
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AUC 95% CI p-value
BE at admission 0.856 0.751 – 0.961 <0.001
BE 1 h after admission 0.915 0.836 – 0.993 <0.001
Lactate at admission 0.784 0.651 – 0.917 0.001
Lactate 1 h after admission 0.825 0.705 – 0.944 <0.001
pH at admission 0.804 0.671 – 0.938 <0.001
pH 1 h after admission 0.905 0.819 – 0.992 <0.001
Shock - Monitoring
Abt et al. Eur J Trauma Emerg Surg 2009
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Damage Control Resuscitation (DCR)
> Permissive hypotension (Cave head injury)
> Minimizing crystalloid-based resuscitation strategies
> Massive transfusion protocols (MTPs): predifined blood products
- PRBCs
- FFP
- platelets
> Adjuncts to massive transfusion:
- Pharmacological adjuncts:
- fibrinogen
- rfVIIa,…
- Auto-transfusion/cell saverNunez et Cotton. Curr Opin Crit Care 2009;15:536-41
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Need For Massive Transfusion
> ED systolic blood pressure <90 mmHg (0=no, 1=yes)
> ED heart rate 120 (0=no, 1=yes)
> Penetrating mechanism (0=no, 1=yes)
> Positive fluid on abdominal ultrasound (0=no, 1=yes)
Assessment of Blood Consumption (ABC) score
Score of 2 predicts 38% need for MT
Score of 3 predicts 45% need for MT
Score of 4 predicts 100% need for MT
Nunez et al. J Trauma 2009;66:346-52
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Duchesne et al. J Trauma 2008;65:272-8
Plasma Transfusion (FFP) versus RBC
4 year
retrospective
study, New
Orleans
p=0.06
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fibrinTAFIa
TAFI
Damage Control of Coagulopathy
pre-kallikrein
FXIIa
FXIFXIa
FIXa
FXII
kallikrein
FXa
FIX
FX
FVIIFVIIIa FVIII
FVFVa
prothrombin (FII)
fibrinogen (FI)
FXIIIa
FXIII
ATIII
ATIII
ATIIIATIII
ATIII
C1-inhibitora1PI
C1-inhibitora1PI
TFPI
protein C-protein S
bradykinin
kininogen
plasminplasminogen
classical pathway
alternative pathway
membrane attack complex (MAC)
C5b,6,7,8,9
C1s
C1 (C1q,C1r,C1s)
C1-inhibitor
C3
u-PA and t-PA a2AP a2MGPAI-1
anaphylatoxinsC3a,C4a,C5a
disseminated intravascular coagulation (DIC)
C5-convertase
opsoninsC3b,C4b
C5
fibrinolytic products
vascular permeability
endothelial + parenchymal cell damages
proinflammatory cytokines, toxins
antigen-antibody-complexes complement cascade
chemotaxis respiratory burst
coagulation system
contact activation
C3-convertase
Keel, Trentz. Injury 2005;36:691
initiationsubendothelial cells
FVIIaTF
amplificationplatelets
propagation
„thrombin burst“ on activated platelets
thrombin (FIIa)
fibrin clots
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Monitoring of Traumatic Coagulopathy
> Plasma-based routine coagulation tests (RCoT):
- Prothrombin time (PT)
- Activated partial thromboplastin time (APTT)
Reflect only small amount of thrombin formed during initiation of coagulation!
> Viscoelastic haemostatic assays (VHA):
- Thromboelastography (TEG®)
- Rotation Thromboelastometry (ROTEM®)
Cell-based model of haemostasis emphasizing importance of tissue factor (TF) as initiator of coagulation and pivotal role of platelets!
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Coagulopathy – Diagnostics
Viscoelastic Haemostatic Assays
Johansson et al. Scand J Trauma Resusc Emerg Med 2009
> Initiation phase:
- reaction time (R)
- clotting time (CT)
> Amplification phase:
- Clot formation time
(K/CFT)
> Propagation phase
(„thrombin burst“):
- alpha angle
- clot strength
- clot stability
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Johansson et al. Scand J Trauma Resusc Emerg Med 2009
Coagulopathy – Diagnostics
Viscoelastic Haemostatic Assays
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Hyperfibrinolysis and Hypofibrinogenaemia
Brenni et al. Acta Anaesthsiol Scand 2009
Fig. 2
Fig. 3
Fig. 4
-140/20 mmHg
-140 /min.
-Lactate 13 mmol/L
-Hb 10 g/dL
-1g tranexamic acid
-7 PRBC
-16g fibrinogen
-3500 ml colloids
-5500 ml crystalloids
3 hours:
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rFVIIa (Novoseven®)
> Trial phase 2 (143 blunt trauma and
134 penetrating trauma, rFVIIa): In blunt
trauma significant reduction of RBC
after rFVIIa (trend in penetrating
injuries); no influence on mortality
Boffard et al. J Trauma 2005;59:8-15
CONTROLTM-„Clinical Trial on the Effect of rFVIIa
on Traumatic Blood Loss“: F7Trauma-1711-Study –multi-
center, randomized, double-blind, parallel group, placebo
controlled trial to evaluate the efficacy and safety of activated
recombinant factor VII (rFVIIa/NovoSeven®/ NiaStase®) in
severely injured trauma patients with bleeding refractory to
standard treatment. Trial Phase 3Global CONTROL Results Meeting
December 2008, Madrid
> Trial phase 3:
- 481 blunt trauma and 92 penetrating
trauma (576 randomized), rFVIIa (200
mcg/kg-1+3h 100mcg/kg)
- in blunt and penetrating trauma
significant reduction of RBC and
FFP after rFVIIa (1.3 U RBC and 2.7
U FFP)
- no influence on mortality or morbidity
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Ongoing Bleeding in CONTROLTM-Study: 22 patients in 28 months (between 2005 and 2008) No 2 worldwideKeel et al. Division of Trauma Surgery, University Hospital Zurich
Case 14
9 pelvic fractures/ 22patients (41%)
† Head
injury† MOF
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> Stage 4: Second Look„s and Schedulded Definitive Surgery
> Stage 5: Secondary Reconstructive Surgery
Damage Control Stages
> Stage 1: Indications
> Stage 2: Damage Control Surgery
> Stage 3: Resuscitation in ICU
Experience
Tactics
Dynamic
FlexibilityWindow of Opportunity
Days 4-10
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Take Home Message: Prevent Death !
> Life Saving Surgery:
– Operative control of airway
– Decompression of cavities
– Surgical control of hemorrhage
– Team
– Tactic
- Time>Fast decision
making for Life
Saving Surgery
and/or DCS/DCO
– Bleeding control
– Reduction of contamination
– Decompression of compartment syndrome
– Resection of avital tissue
– Fixation of skeletal instabilities
> Damage Control Concept