Damage control surgery ....all in one

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.