damage controle resuscitation for trauma patient from anesthesia view on brief

1. Damage control resuscitation
Role of Anesthesiologist
Dr. Ahmed Haggag
MD anesthesia ,ICU and pain management
Al-Azhar university

2. Damage Control
Damage control Resuscitation(DCR)
is a treatment strategy that targets the conditions that
exacerbate haemorrhage in severe trauma patients

3. Key Concepts for DCR
 Permissive hypotension
 Volume replacement By blood products over
whole blood or isotonic solutions
 Early correction of coagulopathy
 Correction of metabolic derangement

4. Trauma team
 Emergency medicine physicians
 Anaesthesiologists
 Trauma surgeons
 Physician/non-physician trauma care

5. Little public discussion of what the
anaesthesiologist can do to facilitate
the overall goals of the trauma team.

6. Airway
Simple non-invasive airway Advanced Airway
nasal canula Non-surgical
simple face mask LMA
Rebreathing face mask ETT
Rebreathing face mask Surgical Airway
Cricothyroidotomy
Tracheostomy

7. Ventilation management
• Mode of ventilation Pressure controlled mode of ventilation is preferred
• Tidal Volume / Ventilating Pressure TV 5-6 ml/kg
• FiO2 As low as necessary to maintain O2 saturation more than 94%
• PEEP and/or Pressure support if needed, Positive intrathoracic pressure will
decrease venous return C.O.
• RR 8-10 breaths/min keeping EtCO2 32 – 40 mmHg

8. Preservation of Homeostasis
• Homeostasis is important to the brain-injured patient
 Any single episode of hypotension or hypoxia increase mortality
from TBI by 4x
 Occurrence of hypotension or hypoxia increase mortality from TBI
by 10x
 Simple normalization of vital signs should not be equated with
restoration of tissue perfusion.
 Occult hypoperfusion is common in young trauma patients

9. Maintain Homeostatic Competence
• Stabilization of BP without recourse to ongoing fluid
administration is the best clinical sign of successful
haemostasis
• Trauma patients without definitive haemorrhage
control should have a limited increase in blood
pressure until definitive surgical control of bleeding
can be achieved
• So, Keeping systolic blood pressure over 80 mmHg
or mean pressure 50-65mmHg is the endpoint of
resuscitation before definitive haemorrhage control

10. Trauma
Hag
e
Acidosis
Coagulopath
y
Hypothermia
Lethal Triad
Fluids administration
Operative exposure

11. Isotonic crystalloids
• Acute haemorrhagic loss or severe traumatic injury
requiring large fluid administration of fluids with a lot of
drawbacks
– Dilutional coagulopathy
– Do little for oxygen carrying capacity needed to correct
anerobic metabolism
– Major cause for hypothermia
– Hyperchloremic acidosis worsening existing acidotic
state of the patient
– Fluids given post-injury have been shown leak and
cause oedema

12. Coagulopathy
• Trauma induced coagulopathy is one of the predictor of
prognosis and at the same time the most significant
challenges to any DCR effort
• Whole blood replacement increase Hct to 40% and more
viable platelets up to 4 folds BUT decreases coagulation
activity to 65% comparing with separated component at
1:1:1 FFP:PRBC:CPP
• More than 5 unites of PRBC lead to dilutional
coagulopathy
• Optimal ratio of FFP to PRBC was 1:1 and this should be
given early in the course

13. Hypothermia
• Severe hypothermia is associated with high
mortality
• Hypothermic patient is hypo-coagulable with body
temp. less than 34°C
• Most cases of hypothermia occur in
• E.R. period of resuscitation
• O.R. Exposed peritoneum

14. Acidosis
• Metabolic acidosis is the physiologic defect resulting from
hypoperfusion corrected with correction of patient
condition
• Acidosis acts with hypothermia affecting coagulation
cascade
• Base deficit and serum lactate serve as guide for
adequacy of resuscitation and markers as an endpoint of
resuscitation
• pH ˂ 7.2 is associated with
• Depressing effect on cardiac contractility, rhythmicity, rate and cardiac
output
• Vasodilatation
• Hypotension

15. Analgesia and Sedation
• Exacerbation of Hypotension Is NOT a contraindication to Anaesthesia
• Volumes and duration of bleeding are known to be worse in the
vasoconstricted subject.
• Anaesthetic or Analgesic Agents move the patient from a
vasoconstricted to a vasodilated state.
 Achieve a deep and stable level of anaesthesia as early as possible in
the care of the unstable trauma patient.
 Begin loading the patient with fentanyl early in the resuscitation, using
small doses at first and responding to drops in BP with boluses of fluid.

16. NOW

17. All Of Us Can Guess Role of
Anaesthesiologist In
DCR

18. Conclusion
• DCR focuses on early, aggressive correction of
lethal triad
• DCR must start in E.R. through O.R. then ICU until
resuscitation is complete
• Anesthesiologist Provides anaesthesia , analgesia
, sedation and preservation of homeostasis