medical ppt

1. Wednesday,
April 12, 2023
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Lethal triad of death
DR. HIWA OMER AHMED
PROFESSOR IN GENERAL AND BARIATRIC
SURGERY
UNIVERSITY OF SULAIMANI
COLLEGE OF MEDICINE – SULAIMANI CITY-
KURDISTAN

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April 12, 2023
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 When penetrating trauma occurs, ,as the
body loses blood, more tissue damage
occurs as hypoxia. Ends in anaerobic
metabolism.

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April 12, 2023
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April 12, 2023
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Acidosis
 One of the by products of anaerobic metabolism islactic
acid “Acidosis”.
 Acidosis has a negative effect on the proteins in the
blood stream that make the blood is unable to clot
“Coagulopathy”

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April 12, 2023
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Coagulopathy
 The bleeding continues and more tissue damage occurs, causing
acidosis to worsen.
 As the blood pressure drops, the tissue’s demand for oxygen-rich
blood exceeds the supply and the body enters a state of shock.
 Attempts to compensate by limiting circulation to the extremities
and maintaining circulation to the vital organs. The heart and
respiratory rate increases, and body temperature begins to drop.

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April 12, 2023
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Hypothermia
 The decrease in body temperature continues to have a negative effect on
the blood’s ability to clot, and bleeding continues.
 As more bleeding occurs, acidosis becomes more severe, causing
worsening shock and progression of hypothermia. What results from this
process is medically known as the trauma triad of trauma (See diagram).
 As the patient becomes more acidotic, more hypothermic, and less able to
form clots, thereby bleeding even more. Without treatment, the patient will
die.


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April 12, 2023
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 Commonly, when someone presents with these signs, damage control
surgery is employed to reverse the effects.

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April 12, 2023
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Damage control
surgery

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April 12, 2023
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 This lifesaving method reverse the physiologic insult prior to completing
a definitive repair.
 While the temptation to perform a definitive operation exists, surgeons
should avoid this practice because the deleterious effects on patients can
result in them succumbing to
 The leading cause of death among trauma patients remains uncontrolled
hemorrhage and accounts for approximately 30–40% of trauma-related
deaths.
 A multi-disciplinary group of individuals is required: nurses, respiratory
therapist, surgical-medicine intensivists, blood bank personnel and others.

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April 12, 2023
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Technique
 Damage control surgery can be divided into the following three phases:
 Initial laparotomy
 Intensive Care Unit (ICU) resuscitation
 Definitive reconstruction.

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April 12, 2023
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1. Laparotomy
 This is the first part of the damage control process
whereby there are some clear-cut goals surgeons
should achieve.
1. The first is controlling hemorrhage
2. followed by contamination control
3. abdominal packing
4. placement of a temporary closure device.
5. Minimizing the length of time spent in this phase is
essential.

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April 12, 2023
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Hemorrhage control
 Solid organ injury (i.e., spleen, kidney) should be dealt with by
resection.
 When dealing with hepatic hemorrhage
1. A Pringle maneuver that would allow for control of hepatic inflow.
2. Surgeons can also apply manual pressure,
3. Perform hepatic packing
4. Plugging penetrating wounds.
5. Certain situations might require leaving the liver packed and taking
the patient for angio-embolization

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April 12, 2023
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Contamination control
 Using staplers to come across the bowel
 Primary suture closure in small perforations.

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April 12, 2023
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Package
 Once this is complete the abdomen should be packed.
 It is important to not only pack areas of injury but also pack areas of
surgical dissection.
 Packing with radiopaque laparotomy pads allow for the benefit of
being able to detect them via x-ray prior to definitive closure.
 As a rule abdomens should not be definitively closed until there has
been radiologic confirmation that no retained objects are present in the
abdomen.

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April 12, 2023
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Temporary closure device
 The most common technique being a negative-vacuum type
device.
 the abdominal fascia is not reapproximated.
 The ability to develop Abdominal Compartment Syndrome is a real
concern.

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April 12, 2023
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2. ICU resuscitation
 On completion of the initial phase of damage control, the key is to
reverse the physiologic insult that took place.
 The intensivist is critical in working with the staff to ensure that the
physiologic abnormalities are treated.
 This typically requires
1. Close monitoring in the intensive care unit
2. Ventilator support
3. Laboratory monitoring of resuscitation parameters (i.e., lactate).

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April 12, 2023
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 The core principles of resuscitation involve
1. permissive hypotension
2. Transfusion ratios
ratio of 1:1:1 of plasma to red blood cells to platelets
3. Massive transfusion protocol.
receiving greater than or equal to 10 units of packed red blood cells
with a 24-hour period
 The resuscitation period lets any physiologic derangements be
reversed to give the best outcome for patient care.

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3. Definitive reconstruction
 Definitive reconstruction occurs only when the patient is
improving.
 Prior to being taken back to the operating room it is paramount
that the resolution of acidosis, hypothermia, and coagulopathy
has occurred

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April 12, 2023
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Steps of definite management
1. The first step after removing the temporary closure device is to ensure that all
abdominal packs are removed.
2. Re-explore the abdomen allowing for the identification of potentially missed
injuries during the initial laparotomy and re-evaluating the prior injuries.
3. Performing the necessary bowel anastomosis or other definitive repairs
(i.e., vascular injuries)
4. An attempt should be made to close the abdominal fascia at the first take back,
5. A method to pre-emptively evaluate whether fascial closure is appropriate
would be to determine the difference in peak airway pressure (PAP) prior to
closure and the right after closure. An increase of over 10mm Hg would
suggest that the abdomen be left open.

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April 12, 2023
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6. Abdominal radiograph to ensure that no retained
sponges are left intra-operatively.
7. After about one week, if surgeons can't close the
abdomen, they should consider placing a Vicryl mesh to
cover the abdominal contents.

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April 12, 2023
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Outcome
40% morbidity
mortality of 50%
 There are four main complications.
1. Intra-abdominal abscess. 83%.
2. Entero-atmospheric fistula, which ranges from 2 to 25%.
3. Abdominal compartment syndrome that has been reported
anywhere from 10 to 40% of the time
4. Fascial dehiscence has been show to result in 9–25%