The document discusses the principles of damage control surgery for trauma patients. It describes the lethal triad of hypothermia, coagulopathy, and acidosis that can occur in critically injured patients and be fatal if not addressed. Damage control surgery follows a staged approach to first control bleeding and contamination, then allow resuscitation and correction of the lethal triad before definitive repair. This strategy focuses on physiological stabilization over anatomical fixation and has significantly reduced mortality rates for severely injured trauma patients.

1. DAMAGE CONTROL
SURGERY
Presenter- Dr
Satish

2. Damage Control – Aim
O Make “ Miraculous” survivals a routine.
O First restore normal physiology then
anatomy.
O Control of hemorrhage and contamination
resuscitation definitive
surgery.*
* S.S.Jaunoo et al. International journal of surgery 7(2009)110-113

3. Damage Control- Principles
O Stone et al -1983 *
O Decrease in mortality at the expence of
increased morbidity.
O Decreased mortality from 98% to 35%.
*Stone et al .Ann Surg 1983;197:532-5.

4. Damage Control – why?
O Traditional surgical teaching*
- control of bleeding
- control of contamination
- definitive surgical repair
Critical patients - definitive surgical repair-
Triad of hypothermia,
coagulopathy,acidosis.
* Hirschberg A et al Surg Clin North Am 1997:77:761-77.

5. Lethal Triad Of Death
O First described – Burch*
O Hypothermia
- Severe exsanguinating injury & resuscitative
attempts. **
- Tissue hypoperfusion & oxygen delivery.
- Affect CVS & immune system.
- Exacerbate the lethal triad .
- Clinically significant - < 36 X 4 hours.
- Mortality 100% - < 32
*Burch JM et al Ann Surg 1992:215(5):476-83
** Jurkovich G et al 1987.J Trauma1987;27:1019-24

6. O Coagulopathy
- Disturbance of balance between
haemostatic & fibrinolytic systems.*
- Hypothermic effects on coagulation.
- Massive fluid transfusion & acidic
environment
- Clinical diagnosis
- Lab diagnosis- PT ,APTT. Fibrinogen
level.
*Johnston TD et al. J Trauma 1994;37;413-7.

7. •The “Bloody vicious cycle”:
-Injurity severity score > 25
-pH < 7.10 + systolic blood pressure < 70
-Core temperature < 34°c
O When all 3 present: incidence of coagulopathy =
98% *
*Cosgriff N, et al. J Trauma 42(5) 1997. 857-862

8. OAcidosis
- Prolonged hypoperfusion
anaerobic
metabolism Lactic acidosis.
- Myocardial depression
- Exacerbates coagulopathy.

9. DEADLY TRIAD
hypothermia
acidosis
coagulopathy

10. Damage Control- Indications
*Asensio
*Injury complexes *
- multiregional exsanguination with viceral
injuries.
- major abdominal vascular injuries with
viceral injuries.
- multiple penetrating or high energy blunt
torso trauma.
* Asensio JA Arch Surg 2004:139:209-15

11. Intraop factors
* Severe metabolic acidosis
pH- <7.2
S. HCO3 - < 15 mEq/l
Lactate > 5 mmol/L
* Hypothermia- < 34
* Coagulopathy-
PT/aPTT - > 50% of normal
massive transfusion >10 units
intraop volume replacement - >12 L
* Asensio JA Arch Surg 2004:139:209-15

12. Damage control
O Staged approach- by Rotondo and Schwab*
. Stage 0 – Prehospital and early resuscitation.
. Stage 1 - Life saving surgery
. Stage 2 - Intensive resuscitation
. Stage 3 – Planned reopertion for definitive
treatment
O *Rotondo MF et al J Trauma 1993;35(3):375.

13. Stage 0
Prehospital and early
resuscitation
O Stop bleeding by compression
O Early transport to hospital
O Prevention of hypothermia
O Early transport to operating room

14. Stage 1
life saving surgery
O Immediate exploratory laparotomy
O Control bleeding
O Control contamination
O Intraabdominal packing
O Rapid closure
O No reconstructive surgery

16. Operative Techniques
O Liver
Perihepatic packing.
Omental packing.
Balloon catheter tamponade.
Absorbable mesh
tamponade.
Hepatotomy with selective
vascular ligation .
Rapid resectional
debridement

17. O Spleen-
splenectomy
O Pancreas-
packing and drainage
O Bile duct-
drainage /ligation.

18. O GI tract
Rapid repair/ resection
Tape ligation of bowel
Use of stapler
No anastomosis/ stoma/ feeding
procedures.

19. O Abdominal arteries
Celiac axis/ splenic artey – ligation
Common hepatic artery – ligation
SMA- intraluminal shunt/ grafting.
Renal artery – nephrectomy.

20. O Aorta – intraluminal shunt/ grafting
O Common & external liac – intraluminal
shunt/ ligation& calf fasciotomy
O Internal iliac- ligation.

21. O SMV- ligation with second look laparotomy
O Common or external iliac vein / infrarenal
IVC
- ligation with calf fasciotomy
- Renal vein - nephrectomy

22. .Chest injuries-
Hilar clamp
stapler ligation/
pulmonary tractotomy
.Exterimity injuries
intraluminal shunting
ligation
.Pelvic injuries
pelvic binder/ external fixation
pre peritoneal packing.

23. Stage II
O Core rewarming
O Correction coagulopathy
O Correction of acidosis
O Ventilatory support
O Monitoring for abdominal compartment
syndrome
O Communication with the family

24. Correction of hypothermia
O Aggravation by surgical intervention or
environmental factors.
O Early termination of surgery.
O Perioperative management- remove wet clothings,
increase room temperature,warm resuscitation
fluids and ventilation system and temperature
regulating blankets.
O Warm till 37 degree C within 4 hrs, if not & remain
<35 , consider pleural lavage.*
O If temp remain <33, continous A-V rewarming.
* Rotondo MF, et alJ Trauma 1993;35(3):375.

25. Correction of coagulopathy
O The 10 unit rule( 10 units each of RBC,FFP &
platelets) within the first 24 hrs.
O Administration of blood products continued
until PT is less than 15s & PC are >
100000/mm3.
O Cryoprecipitate – when fibrinogen level
<100mg/dl & repeat after every 4 hours.*
O Recombinant factor VIIa.**
*Hirshberg A et al J Trauma 1992;37:365–9.
**Levi M et al Crit Care Med 2005;33:883–90.

26. Correction of acidosis
O It corrects itself with adequate resucitation
& rewarming.
O Once oxygen dept is repaid the body
switches from anerobic to aerobic
metabolism.

27. Stage III
Planned re-opertion for definitive
treatment
O Timing – after adequate stabilization
usually by 36 hours( 24-48 hours)
.Reinspetion for bleeding and missed
injuries
.Definitive repair
.Feeding procedures
.Closure of abdominal wall

28. Complications
.Abdominal compartment syndrome
. Wound sepsis & wound dehiscence
. Fistula formation.
.Incisional hernia

29. Conclusion
O Evolving attitude in the trauma patients.
O Focus on physiological optimisation prior
to anatomical repair.
O Led to improved survival rate due to timely
management of lethal triad.

30. “For he who fights & runs away, may live to
fight another day,But he who is in battle
slain can never rise & fight again.”
-Oliver goldsmith.