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Damage control surgery (Bruno Pereira WSACS session ESA 2018 #EA18)

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Despite the word “war” refer to a bad feeling it is undeniable that military conflicts have always driven innovation and technical advances in medicine and surgery. Accepted concepts of trauma resuscitation and surgery have been challenged in the recent wars, and novel approaches have been developed to address the current complexity and severity of not only military trauma but also civilian conflicts.

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Damage control surgery (Bruno Pereira WSACS session ESA 2018 #EA18)

  1. 1. DAMAGE CONTROL SURGERY PARAMETERS TO DECIDE ESA 2018
  2. 2. BRUNO M PEREIRA MSc, PhD, FACS, FCCM Prof. Adjunto Disciplina de Cirurgia do Trauma UNICAMP BRUNO M PEREIRA MSc, PhD, FACS, FCCM Trauma Surgery Division UNICAMP ● Acute Care and Trauma Surgery ● Surgical Critical Care ● President – WSACS 2017-2019 ● Director – Disasters Committee, SPT (2014-2016) Prof. Dr. Nothing to disclose
  3. 3. DAMAGE CONTROL WHEN TO INDICATE ? EASY QUESTION ?
  4. 4. WHERE TO GO ON THE RIGHT MOMENT?
  5. 5. NO CONSENSUS BAD NEWS !!!! MAY BE WE SHOULD START WITH VITAL SIGNS
  6. 6. DAMAGE CONTROL CONCEPT ● Physiology consumption – no physiologic reserve anymore ● Restore patient physiology ● Stop bleeding, Control Contamination, ICU ● Temporary closure and planned re-exploration
  7. 7. DAMAGE CONTROL Resuscitation
  8. 8. Di Saverio et al in: Trauma Surgery, Vol 1, 2014, Chapter III, Springer, USA. BUT ONCE PRESENT IT MAY BE TOO LATE
  9. 9. TEAM COMUNICATION IS ESSENTIAL
  10. 10. WHAT THE EVIDENCE SHOWS?arrest, April 2012 ● SBP/ BE – 7.5 / Core Temp <35.5˚C. Matsumoto et al, 2010 ● Mechanism of Trauma. Parreira et al, 2002 ● Blood loss and PRBC transfusion. Asensio et al, 2001 ● Coagulopathy. Cosgriff et al, 1997 ● Number of lap pads used on surgery, Garrison et al, 1996 LITERATURE
  11. 11. SUMMARY SOME EVIDENCES FROM LAST PUBLICATIONS Author Year Garrison 1996 Cosgriff 1997 Rotondo 1997 Asensio 2001 Parreira 2002 Germanos 2008 Matsumoto 2010 Design (N) Prospec (N=70) Prospec (N=58) Review Prospec (N=548) Prospec (N=74) Review SR/ MA (N=34) Indication Criteria Number of Lap Pads used on surgery Predictive values of coagulopa- thy - ≥ 2 L BL or ≥ 1.5 L PRBC Shock, Mechnism of injury - Shock, Mechnism of injury SBP/ Temp ≤ 90 mmHg/ - ≤ 70 mmHg < 34˚C - / - - / ≤ 34˚C - / < 110 mmHg < 70 mmHg ≤ 34˚C ≤ 90 mmHg ≤ 35.5˚C pH/ BE < 7.2 / - < 7.1 / - < 7.3 / - < 7.2 / < `- 12 mEqL < 7.25 / < - 10 mEqL < 7.2 / - - / < -7.5 Blood alterations > 15 PRBC Coagulopa- thy >10 PRBC 4L lost > 12 PRBC 5L lost Persistent Shock > 10 PRBC Persistent Shock -
  12. 12. ● Specific method for Trauma ● Major Objectives: o Improve physiology o Stop the Bleeding o Control Contamination ● Decide: o Damage Control vs Definitive Treatment DAMAGE CONTROL REMEMBER ● Select the correct patient
  13. 13. ● Take it as soon as possible ● Recognize “trauma glues” ● Remember on physiology ● Chat with your team CRITICAL DECISION
  14. 14. TIPS IMPORTANT ● Pay attention on HOSTILE physiology o Check ABG’s o Edema of bowel mucosa o Midgut distension o Dusky serosal surface o Tissue cold on touch o Non-compliant swollen abdominal wall o Diffuse oozing from surgical incisions IF YOU’RE YET TO TAKE A CRITICAL DECISION…
  15. 15. OPERATING ? STILL IT IS TIME TO BAIL OUT!!! ● Injury PATTERNS indicating the need for BAIL OUT o Combined major vascular and hollow visceral injuries o Penetrating injury to the “surgical soul” o High grade liver injury o Pelvic fracture with an expanding pelvic hematoma o Injuries requiring surgery in other cavities (chest, head, neck)
  16. 16. IT IS ALL ABOUT CRITICAL THINKING ● Critical thinking is based on evidence and logical reasoning. Emotions and memorization are not a part of logical thinking ● Critical thinking requires evaluating and improving your own thought processes. It relies on universal intellectual values like clarity, relevance and consistency KEY POINT IMPORTANT
  17. 17. ● Improved cognitive skills ● A foundation of logical decision making on which you can draw, even in stressful situations; and, ● Higher academic and professional achievement POSITIVE CRITICAL THINKING EFFECTS
  18. 18. ● Critical thinking forces intellectual self improvement ● Critical thinking allows you to become a better team player ● Critical thinking leads to a more creative mindset ● Critical thinking helps you stay calm and rational under stress ● Think about the impact critical thinking skills can have in your context CRITICAL THINKING AND DECISION MAKING
  19. 19. VALID FOR THE ENTIRE TEAM
  20. 20. ON TRAUMA SIMULATION Lack of critical thinking and decision making is often observed
  21. 21. Campinas, Brazil – 29th May – 01st June 2019
  22. 22. BRUNO M PEREIRA MSc, PhD, FACS, FCCM Dr.bruno@gruposurgical.com.br

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