Dr. Yasser Abbas Department of General surgery

Concept of Damage control

History

Indications of Damage Control.

Damage Control Sequence.

Complications.

Summary.

Outlines

“ …keeping afloat a badly damaged ship by procedures to limit flooding , stabilize the vessel, isolate fires and explosions and avoid their spreading”

Surface ship survivability, Naval war publication

3-20.31, Washington, DC. Department of defense; 1996

Concept of Damage control

Definitive Surgery Approach?

“The operation was a success but the patient died anyway.”

– Anonymous

“He who fights and runs away, may live to fight another day.” – JA Aulls, 1876

Damage Control Approach ?

History

In 1983, Stone was first to describe the “bailout” approach .

14 patients :

Per-operative correction of coagulopathy

Definitive surgery

1 survivor

17 patients:

OR and packing

Correction of coagulopathy in ICU

Re exploration in OR

11 survivors

The concept of DC was initially described for intra-abdominal trauma, it has been expanded to :

Thoracic.

Extremity vascular.

Orthopedic injuries.

“Damage Control Resuscitation”. 1c

The Concept Expansion

Indications of DCHigh-energy blunt torso trauma

Multiple penetrating torso injuries

Hemodynamic instability

Coagulopathy on presentation or during operation

Severe metabolic acidosis (pH < 7.2 or base deficit > 8)

Hypothermia on presentation (< 35°C)

Prohibitive operative time required to repair injuries (> 90 min)

Multiple visceral injuries with major vascular trauma

Multiple injuries across body cavities

Massive transfusion requirements (> 10 units packed red blood cells)

Presence of injuries better treated with nonsurgical adjuncts

The Lethal Triad

It is Better to Cure in Phases rather than to Kill in one

- Anonymous

Prehospital care & Initial resuscitation:

Built on fundamentals of ATLS guidelines.

Rapid Transport to definitive care.

Rapid Evaluation.

FAST, Tube Thorocostomy , CXR, Pelvis X-ray, etc…

Damage Control Resuscitation to systolic 80-90 mmHg.

This phase should take 20-30 min.

DC SequenceGround 0

A DC approach should be taken with any patient in the

ED who has :

Revised Trauma Score ( RTS ) ≤ 5

Requires ≥ 2,000 ml of crystalloids for resuscitation in the ER.

Requires ≥ 2 units of PRBCs for resuscitation in the ER.

A pH of ≤ 7.2

Strength of evidence: C.

Asensio J, et al. Am J Surg 2001; 182: 743–51.

How do We Predict in ED ?

Control of Hemorrhage and Contamination:

Laparotomy

Evacuation of blood.

Four quadrant packing.

Full exposure of the injuries.

Kocher maneuver

Cattell-Braasch

Mattox

DC SequencePart 1(OR)

Solid organs: such as spleen and isolated kidney , are sacrificed in damage control if repair prolongs surgical times.

Bleeding vessel : Ligation /shunting.

Bowel injury: stapler/ ligation.

Intra-abdominal Packing

Temporary abdominal closure

This phase shouldn`t take more than 90 min.

DC SequencePart 1(OR)

Incisions in DC

Retroperitoneal Zones

Kocher Maneuver

Cattell-Braasch

Mattox

Liver Packing

Patients who require ≥ 4,000 ml PRBCs.

Patients who have had an ED or OR. thoracotomy.

pH ≤ 7.2

Temperature of ≤ 34°C

Inaccessible major venous injury

Intraoperative ; How to identify the patient for DC ?

If the surgeon cannot achieve hemostasis owing to coagulopathy

If the definitive operative repair is a time-consuming procedure in the patient with suboptimal response to resuscitation

If the patient requires the management of an extra-abdominal life-threatening injury

Intraoperative ; How to identify the patient for DC ?

If the patient will require a reassessment of intra-abdominal contents

If the surgeon cannot re-approximate the abdominal fascia due visceral edema.

Strength of recommendation: D.

Shapiro M, Jenkins D, Schwab C, et al. J Trauma 2000; 49: 969–78.

Rotondo M, Zonies D. Surg Clin N Am 1997; 77: 761–77.

Loveland J, Boffard K. Br J Surg 2004; 91: 1095–101

Intraoperative ; How to identify the patient for DC ?

Core temperature ≤ 34°C

pH ≤ 7.2

Prothromin time ≥ twice normal

Partial thromboplastin time ≥ twice normal

Strength of recommendation: B.

Ferrara A, MacArthur J, Wright H, et al. Am J Surg 1990; 160: 515–18.

Cosgriff N, Moore E, Sauaia A, et al. J Trauma 1997; 42: 857–61; discussion 861–2.

Garrison J, Richardson J, Hilakos A, et al. J Trauma 1996; 40: 923–7; discussion 927–9.

When We Terminate the Surgery?

Correct Acidosis and Coagulopathy

Rewarm the patient

Optimize oxygenation and ventilation

Measure Intra abdominal pressure. ( 1A)

Part 2: Resuscitation(ICU)

Careful removal of packs

Inspection of all injuries

Control of bleeding points

Definitive GIT repair

Thorough washout

Avoid stomas and tube entrostomies if possible

Temporary vs. definitive closure

Part 3: (OR 2)

Temporary closure of the open abdomen is best accomplished : VAC Dressing. and a fascial tensioning.

Abdominal closure is best accomplished by hospital day 8 to reduce morbidity.

Strength of recommendation: C.

Barker D, Green J, Maxwell R, et al. J Am Coll Surg 2007;204:784–92. Offner P, de Souza A, Moore E, et al. Arch Surg 2001; 136: 676–81.

Garner G, Ware D, Cocanour C, et al. Am J Surg 2001; 182:630–8.

Part 4: Open Abdominal Wounds

Temporary Abdominal Closure

Mesh closure and Tightening

Definitive Repair

Outcome

Before After

Outcome

Before After

Outcome

DC Timeline

Reuven Rabinovici, et al. , Trauma, Critical care & surgical emergency. 2010

Expected complication rate from damage control ranges from 25% to 40% .

The most common complications :

Intra-abdominal abscesses

Enterocutaneous fistulae.

Strength of recommendation: C.

Abikhaled J, Granchi T, Wall M, et al. Am Surg 1997; 63: 1109–12; discussion 1112–13.

Sharp K, Locicero R. Ann Surg 1992; 215: 467–74; discussion 474–5.

Complications of DC

The management of exsanguination requires leadership, prompt thinking and aggressive surgical intervention.

Delays in the decision to perform DC contribute to a higher morbidity and mortality.

DC is a vital part of the management of the multiply injured patient and should be performed before metabolic exhaustion.

Summary