damage control surgery, trauma, resuscitation, multiply injured, polytrauma

1. D R B A S H I R Y U N U S
S U R G E R Y R E S I D E N T
DAMAGE CONTROL
SURGERY

2. INTRODUCTION
• A form of surgery by trauma surgeons for critically
traumatized patient to stabilize the injuries, targeted
at prevention of the triad of death (Hypothermia,
acidosis and coagulopathy) rather than the
correction of anatomy.

3. DEFINITION
• Damage control surgery is defined as the
rapid initial control of hemorrhage and
contamination with packing and temporary
closure, followed by resuscitation in the ICU,
and subsequent re-exploration and
definitive repair once normal physiology has
been restored.

4. PRINCIPLES
• Control haemorrhage
• Identification of injury
• Prevention contamination
• Avoid further injury

5. Hypothermia:
• Clinically important if less than 37⁰C for more than 4
h
• Can lead to cardiac arrhythmias, decreased
cardiac output, increassed systemic vascular
resistance
• Can induce and exacerbate coagulopathy by
inhibition of clotting cascade reaction

6. Acidosis:
• Uncorrected haemorrhagic shock leads into
inadequate cellular perfusion, anaerobic
metabolism and the production of lactatic acid
• Interferes with blood clotting mechanisms and
promotes coagulopathy and blood loss

7. Coagulopathy:
• Hypothermia, acidosis and the consequences of
massive blood transfusion all lead to the
development of a coagulopathy
• Platelet dysfunction at low temperature
• Activation of the fibrinolytic system
• Haemodilution following massive resuscitation

8. WHEN TO INSTITUTE
Parameters as a guideline for instituting damage control:
• pH less then or equal to 7.2
• serum bicarbonate level less than or equal to
15 mEq/L
• core temperature less than or equal to 34⁰C
• transfusion volume of packed RBCs more than
or equal to 4000 ml
• total blood replacement more than or equal to
5000 ml
• total fluid replacement more than or equal to
12 000 ml
If all - death
If one - DCS

9. PHASES

10. APPROACH
Before
ER OR DEATH
Now
ER→OR→ICU→OR→ICU
ER; emergency room, OR; operating room;

11. STAGE 1 DCS (ABDOMEN)

12. • initial laparotomy
• identify the main source of bleeding
• perihepatic packing (superior and inferior)
• small gastotomies and enterotomies can be
rapidly closed
• resect non-viable bowel and close the ends
• minor pancreatic injuries not involving duct-
no treatment
• distal injury including the panceratic duct-
distal pancreatectomy
• NO pancreaticoduodenectomy (drainage)
• abdominal closure is rapid and temporary- if
there is any doubt about abdominal
compartment syndrome, left it open (silo-
bag, vacuum-pack technique, towel clip)

14. STAGE 1 DCS (SKELETAL)

15. • Stable patient – osteosynthesis
• Polytrauma patient- FE
• Do not insist on anatomical reposition, but on
fracture stabilisation
• Open fracture-debridment
• Control all hemorrhages primarily.
• Avoid early manipulations of long bone fracture.
• Prevents fat embolism.
• Two hit theory.

16. DAMAGE CONTROL NEUROSURGERY
1. Arrest intracranial hemorrhage.
2. Evacuate the hematoma.
3. Primary closure of dura to prevent
infection.
4. Craniectomy to prevent
compartment syndrome.

17. STAGE 2 DCS
• Begins in ICU
• The next 24 to 48 hours are crucial
• Correction of metabolic disorder
• Core rewarming
• Correction of coagulopathy
• Complete ventilatory support
• Correction of acidosis
• Identification of occult injury

18. STAGE 3 DCS – PLANNED REOPERATION
• Window of opportunity is 24-48 hours after the
trauma- between the correction of metabolic
disorder and the onset of SIRS and MOF
• Removal of the abdominal packs (48-72 h)
• Primary repair with end-to-end anastomosis
undertaken
• Copious washout should be performed and the
abdomen closed
• The patient sometimes needs early unplanned
reoperation-ongoing haemorrhage, abdominal
compartment syndrome or peritontis
• Window of opportunity for definitive osteosynthesis is
5-10 days after trauma

19. INDICATIONS FOR DEFINITIVE
SURGERY
1. Core temperature 36°C or above
2. Correction of acid base balance
3. Normalization of coagulation profile.

20. ADVANTAGES
A. A small study on penetrating abdominal
injuries showed a survival benefit over
historical controls(90% v 58%; P=0.02).
B. Mortality in Iraq war was 10% compared with
24% in Gulf war.

21. DISADVANTAGES
1. Sepsis and multi organ failure
2. Pneumonia
3. Intra abdominal abscess
4. Enteric fistula
5. Compartment syndrome

22. REFERENCES
• Brian J. Eastridge et al; Damage control surgery
• Dr. Josip Janković, Dr. Boris Hrečkovski Department of surgery
General hospital Slavonski Brod
• www.slideshare.net