Damage control-surgery

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Damage Control Surgery
Sanda Pudule
Supervisor: Ruta Jakušonoka
22.11.2016., Rīga

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

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 Damage control surgery (DCS) is a concept of
abbreviated laparotomy, designed to prioritize short-
term physiological recovery over anatomical
reconstruction in the seriously injured and
compromised patient.[1]
Definition
[1] http://bja.oxfordjournals.org/content/113/2/242.full

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 Damage control – military term used
to describe a ship’s ability to
maintain its mission after being
damaged.
 1983 – first published papers on the
matter of damage control;
 1993 – first adaption clinically, by
Schwab et al
History
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3908997/

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 Hypothermia
 Coagulopathy
 Metabolic acidosis
The «Lethal triad»
http://www.jems.com/articles/print/volume-39/issue-4/features/trauma-s-lethal-triad-hypo

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

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 Result of severe exsanguinating injury and
subsequent resuscitative attempts.
 Severe haemorrhage leads to an inability to generate
heat.
 Clinically significant:
»360C – more than 4h;
»320C – 100% mortality rate;
Hypothermia

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 Occurance of:
»Cardiac arrhythmias;
»Reduced cardiac output;
»Increased systemic vascular resistance
»Shifting of the oxygen-dissociation curve to the left;
 Immune system – suppressed;
 Bleeding is increased due to:
»Disfunction of coagulation factors;
»Platelet dysfunction;
»Abnormalities, alterations in the fibrinolytic system;
Hypothermia

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 Dissbalance between heamostatic and fibrinolytic
systems;
 Hypothermia reduces metabolic rate of coagulation
factors;
 Clinical dg:
»Non-surgical bleeding from wounds, serosal surfaces,
vascular access sites, skin edges.
 Laboratory dg:
»Fibrinogen levels, Protrombine time, partial protrombine time
Coagulopathy

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 Prolonged hypoperfusion -> anaerobic
metabolism ->lactic acidosis
 Results:
»Contractility of myocard is decreased, leading to reduction of
cardiac output.
»Coagulation factors are inactive because of acidic
environment.
Metabolic acidosis

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 Stage I: abbreviated resuscitative surgery
 Stage II: CCU* resuscitation
»Hypothermia
»Coagulopathy correction
»Correction of acidosis
 Stage III: definitive surgery
Stages of damage control surgery
*Critical Care Unit

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 Control of hemorrhages;
 Control of fecal spillage (to minimise contamination);
 Packing;
 Temporary abdominal closure;
 External fixation, splinting (to immobilize);
Stage I: abbreviated resuscitative
surgery

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

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 Within 36-48h;
 Gastrointestinal continuity;
 Abdominal closure;
 Definitive stabilization of fractures, other injuries;
Stage III: definitive reconstructive
surgery

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 Stabilization
 Staged definitive management
»Initial pelvic volume reduction (sheet, pelvic packing,
external fixation etc.)
»Hemodynamically stable -> CT imaging
»Hemodynamically unstable -> pelvic angiography and
embolization
 Definitive treatment
»After 5 days
Damage Control Orthopedics
http://www.orthobullets.com/trauma/1005/evaluation-resuscitation-and-dco
H.C.Pape et al.”Damage control management in the polytrauma patient” Springer, 2010.

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 Clinical parameters:
»pH 7.2 or less;
» intra-operative core temp.340C or less;
»Transfusion volume or packed RBCs 4000 ml or more;
»Total blood replacement 5000ml or more;
»Total fluid replacement 12 000ml or more;
 Physiological parameters:
»High energy, blunt torso trauma;
»Multiple torso penetrations;
»Hemodynamic instability;
»Coagulopathy and/or hypotermia on admission;
When to initiate damage control?

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 Wound infection;
 Abdominal abscess;
 Wound dehiscence;
 Bile leak;
 Enterocutaneous Fistula;
 Abdominal Compartment Syndrome;
 Multisystem Organ failure;
 Mortality;
Complications of Damage Control

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Case report
by Mayr J et al.

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Damage Control Resuscitation in a 12-
Year Old Girl with Severe Thoraco-
Abdominal Polytrauma
http://trauma-acute-care.imedpub.com/damage-control-resuscitation-in-a-12year-old-g

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Damage Control Resuscitation in a 12-
Year Old Girl with Severe Thoraco-
Abdominal Polytrauma
http://trauma-acute-care.imedpub.com/damage-control-resuscitation-in-a-12year-old-girl

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Damage Control Resuscitation in a 12-
Year Old Girl with Severe Thoraco-
Abdominal Polytrauma
http://trauma-acute-care.imedpub.com/damage-control-resuscitation-in-a-12year-old-gi

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

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

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 https://www.youtube.com/watch?v=J6Zz0I6sfaM
 S.S. Jaunoo*, D.P. Harji, Department of General Surgery, Worcestershire Royal Hospital,
Charles Hastings Way, Worcester WR5 1DD, United Kingdom, Damage control surgery,
International Journal of Surgery 7 (2009) 110–113, 2009.
 http://bja.oxfordjournals.org/content/113/2/242.full
 http://trauma-acute-care.imedpub.com/damage-control-resu
References

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 http://www.medscape.com/viewarticle/829159
 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC39089
97/
 http://www.orthobullets.com/trauma/1005/evaluation-
resuscitation-and-dco
 http://www.slideshare.net/bashirbnyunus/damage-
control-surgery-44230609
References

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 H.C.Pape et al.”Damage control management in the
polytrauma patient” Springer, 2010.
 Pape HC, Sanders R, Borelli J, editors. The Poly-
Traumatized Patient with Fractures. A Multi-Disciplinary
Approach. Berlin, Heidelberg: Springer - Verlag; 2011.
References

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Thank You
for
Your attention! 