2. Definition
Loss of entire blood volume equivalent within 24hrs
Loss of 50% of blood volume within 3hrs
Continuing blood loss of 150ml/min
Continuing blood loss of 1.5ml/kg/min over 20 min
Rapid blood loss leading to decompensation and
circulatory failure despite volume replacement and
interventional treatment
4. DAMAGE CONTROL RESUSCITATION
Damage control resuscitation (DCR) is a treatment
strategy that targets on the conditions that exacerbate
hemorrhage in trauma patients.
It is a systematic approach to major trauma
incorporating several strategies to decrease mortality
and morbidity:
1. Permissive hypotension(Minimal Normotension)-
maximize tissue perfusion whilst minimizing clot
rupture and excessive blood loss.
2. Haemostatic resuscitation(Massive Transfusion
Protocol)
3. Hemorrhage Control(Damage control surgery)
5. DAMAGE CONTROL RESUSCITATION
DCR centers on the application of several key
concepts,
Permissive hypotension,
Use of blood products over isotonic fluid for
volume replacement and
Rapid and early correction of coagulopathy with
component therapy.
6. Cont.
Resuscitative methods classffied in to four stages,
Rescue or salvage phase: aimed at re-establishing the
minimum perfusion necessary to sustain life
Optimization phase: aimed at preventing
decompensation
Stabilization phase: aims at maintaining a patient's
normal physiologic systolic and mean arterial
pressures.
Deescalation phase: aims at slowing down and
removing fluid administration in order to evaluate a
patient's independent stability following supportive
therapy and fluids.
7. 1.PERMISIVE HYPOTENSION
Keep the blood pressure low enough to avoid
exsanguinations while maintaining perfusion of end
organs.
“Injection of a fluid that will increase blood pressure has
dangers in itself if the pressure is raised before the
surgeon is ready to check bleeding,
Prevent “clot bursting”/dislodgement
Avoid excessive fluid administration
generally been used only in the initial rescue and
optimization phases of recovery.
8. 1.PERMISIVE HYPOTENSION
Early use of blood components as the primary
resuscitation fluid instead of crystalloid/colloids.
Aggressive use of crystalloid is associated with
increased mortality in hemorrhagic shock such as:
1. Increased haemorrhage -increased clot rupture with
restoration of normal BP
2. Dilutional coagulopathy
3. Dilutional anaemia – impaired oxygen delivery
4. Hypothermia
5. Metabolic Acidosis (N. Saline)
6. Lowers plasma oncotic pressures -haemodilution
9. 1.PERMISIVE HYPOTENSION
“When the patient must wait for a considerable period,
elevation of his SBP to 85 mmHg is all that is necessary
when profuse internal bleeding is occurring, it is
wasteful of time and blood to attempt to get a patient’s
blood pressure up to normal.
One should consider himself lucky if a systolic pressure
of 80 to 85 mmHg can be achieved and then surgery
undertaken.”
Trauma patients without definitive hemorrhage control
should have a limited increase in blood pressure.
11. 2.Haemostatic resuscitation principles
1. Identify at risk group as early as possible( Massive
Transfusion Protocol)
2. Early use of blood components as the primary
resuscitation fluid instead of crystalloid/colloids
3. Use in the same ratio as they are lost through
haemorrhage (Exact ratios are controversial)
PRBC:FFP:Platelets 1or2:1:1
4. Give Tranexamic Acid
5. Prevent hypothermia
6. Prevent acidosis
7. Monitor and maintain Ca2+
13. 3.DAMAGE CONTROL
SURGERY
Damage control surgery are performed in injured patients
with profound hemorrhagic shock and preoperative or
intraoperative metabolic unstable that are known to
adversely affect survival.
Initiating resuscitation in the operating room for patients with
severe hypotension, cardiac arrest, or external hemorrhage.
Early operative control of hemorrhage.
14. Three Phases of Damage Control
Surgery
1. Initial operation with hemostasis and packing
2. Transport to the ICU to correct the conditions of
hypothermia, acidosis, and coagulopathy
3. Return to the OR for definitive repair of all
temporized injuries
15. WHO NEEDS DCS??
Thoracic Trauma
Penetrating thoracic wound and systolic blood
pressure <90 mmHg.
Pericardial fluid on surgeon-performed
ultrasound after blunt or penetrating thoracic
trauma.
Trauma to an Extremity
Shotgun wound to femoral triangle of thigh
16. WHO NEEDS DCS??
Abdominal or Pelvic Trauma
Penetrating abdominal wound and systolic blood
pressure <90 mmHg
Blunt abdominal trauma, systolic blood pressure
<90 mmHg, and peritoneal fluid on surgeon-
performed ultrasound or gross blood on
diagnostic peritoneal tap.
Closed pelvic fracture, systolic blood pressure
<90 mmHg, and peritoneal fluid on surgeon-
performed ultrasound or gross blood on
diagnostic peritoneal tap
Open pelvic fracture
21. Hypothermia
Severe hypothermia is associated with a high
mortality
<35 deg - platelet dysfunction
<33 deg - clotting enzyme
synthesis/kinetics,plasminogen activator
Progressive delay in the initiation of thrombus
formation
Causes might be:
Pre-hospital
ED - resuscitation period
Theatre - exposure of peritoneum, resuscitaton fluids
23. Trauma induced coagulopathy
Definition:
Intrinsic dysregulation of the blood coagulation in
the setting of trauma
Pre-requisistes:
Tissue Hypoperfusion
Physical Tissue Damage
Factors released by the tissue and endothelium in
response to injury and hypoxia cause
coagulopathy by several mechanisms:
1.Anticoagulation
2.Thrombin-thrombomodulin Protein C system
dysfunction
3.Platelet dysfunction
4.Hyperfibrinolysis
25. ACIDOSIS AND BASE EXCESS
Both are independent predictive factors of mortality
and identify anaerobic metabolism (tissue
hypoperfusion)
pH strongly affects activity of Factors V, VIIa and X
Acidosis inhibits Thrombin generation
pH<7.2 - decreased contractility and CO, vasodilation,
hypotension, bradycardia, dysrhythmias
Lactate is demonstrated to have the best association
with hypovolaemic shock and death - useful marker as
an endpoint of resuscitation
26. CRYOPRECIPITATE
Fibrinogen (plus platelets) is the
primary substrate for clot
formation
Reduced fibrinogen levels
correlate with increased mortality
If fibrinogen is <1.0g/L give
Cryoprecipitate
Contains: Fibrinogen, Factor
VIII, vWF, Factor XIII
27. TRANEXAMIC ACID
TXA is an anti-fibrinolytic agent
The effect of TXA on mortality in a
bleeding patient is time dependant -
survival advantage if given early.
28. Perioperative management
A thorough pre-operative evaluation is fundamental for
o Stratifying hemorrhagic risk
o Predicting transfusion needs in relation to the type of
surgical intervention
o Evaluating the indications and eligibility of a patient for
auto transfusion procedures, and
o The need for any adjuvant therapies
