damage control resuscitation in trauma

1. MAJOR TRAUMA:
CONCEPT OF
DAMAGE CONTROL
RESUSCITATION&
SURGERY
Dr.Verdah Sabih
PGT Anesthesia
Holy Family Hosp.Rwp

2. OBJECTIVES
 Scoring systems: How to triage
 Components of trauma management
 Damage control resuscitation measures
 Damage control surgery
 Targets

3. TRAUMA OVERVIEW
 Trauma is the leading cause of death in adults aged
younger than 45 years
 Accounts for around 10% of the world's deaths
 ‘Time critical injuries’ requiring specialist
interventions or emergency surgery.
 a successful outcome depends on the quality of the
initial resuscitation and correct prioritization of
treatment

4. SCORING SYSTEMS:
1. Abbreviated Injury Scale (AIS):
 Grades injuries anatomically according to a detailed 6-point
severity scale
 (1 – minor, 2 – moderate, 3 – serious, 4 –severe, 5 – critical and 6
– maximal (currently untreatable))
 In nine body regions (head, face, neck, thorax, abdomen, spine,
upper extremity, lower extremity, external/others)
2. Injury Severity Score (ISS):
 Focuses on six body regions (head/neck, face, chest,
abdomen/pelvis, extremities/pelvic girdle, external)
 Sum of the squares of the AIS severity scores of the three most
severely injured regions.
 The score ranges from 1–75 (i.e. a severity of 5 in each group)
 If any of three scores is a 6 (un-survivable injury), the score is
automatically set to 75.
 Major trauma is defined as ISS greater than 15 and moderately
severe trauma as ISS 9–15.

5. 3.Revised Trauma Score (RTS):
 Physiological score based on the initial Glasgow Coma
Scale (GCS ) score, systolic blood pressure and
respiratory rate
 Used to predict survival and as a triage tool.
 Score from 0–4 in each category.

6. COMPONENTS OF TRAUMA
MANAGEMENT:
1. Rapid Primary Survey
2. Damage Control Resuscitation
3. Ongoing Repeated Examinations
4. Definitive care

7. 1.PRIMARY SURVEY
 cABC approach
 Catastrophic hemorrhage control
 Airway
 Breathing
 Circulation
 Strong emphasis on hemorrhage control.
 Control of exsanguinating hemorrhage methods??

8. AIRWAY/BREATHING:
 Airway assessment reveals one of three clinical
scenarios:
a) Patient is conscious, alert, talking.
b) Patient has a reduced conscious level but some
degree of airway control and gag reflex still present.
c) Patient has a reduced conscious level, and gag reflex
is absent

9. WHEN CONFRONTED WITH AN UNCONSCIOUS
TRAUMA VICTIM, WHAT TO DO??
 Establish the patency of the patient's airway whilst
ensuring immobilization of the cervical spine
 If upper airway obstruction is present, the pharynx
should be cleared of any debris and a jaw-thrust
performed;
 Chin-lift should be avoided as greater degree of
cervical spine movement.
 If the patient is apneic, facemask ventilation with
100% oxygen must be started immediately to
ensure adequate oxygenation.

10.  For tracheal intubation cervical collar should be
unfastened at the front to allow easier laryngoscopy
and the application of cricoid force (if necessary)
 Cervical spine should be protected by manual in-
line immobilization
 Bougie or video laryngoscopy
 During laryngoscopy it not necessary to obtain the
‘best possible’ view of the glottic opening
 Common indications for tracheal intubation in
emergency dept.??

11. CIRCULATION:
 Significant shift in the resuscitation strategy
 Move away from ‘full’ resuscitation and ‘definitive’
surgery towards a concept of damage control
resuscitation (DCR).
 Term hybrid resuscitation is used to describe the
combination of time-limited permissive hypotension
with hemostatic resuscitation
 Target: Presence of a central pulse (approx. systolic
blood pressure 70mmHg) is deemed to be evidence
of adequate perfusion until the source of bleeding is
controlled

12. WHY NECESSARY??
 Urgent restoration of sufficient circulating blood
volume to ensure:
 Adequate oxygen delivery to the tissues;
 Stabilization and/or correction of metabolic
derangements;
 Correction of acute traumatic coagulopathy (ATC) and
prevention of iatrogenic coagulopathy

13.  Initial response to adequate boluses of warmed
isotonic fluids may give some guide as to degree of
hypovolemia
 If a patient has clear signs or a strong history
suggestive of significant blood loss, blood should
be given at the earliest opportunity.
 All fluids given must be warmed, as the triad of
hypothermia, acidosis and clotting derangement
can be lethal.
 Peripheral Large-bore i.v. access and fluid warming
devices

14. DAMAGE-CONTROL RESUSCITATION
MEASURES
 Limited crystalloid infusions
 Permissive hypotension
 Hemostatic resuscitation and treatment of Acute
traumatic coagulopathy & hypocalcemia
 Rapid hemorrhage control with early damage
control surgery;
 Regaining homeostasis with aggressive
temperature management to treat or avoid
hypothermia

16. PERMISSIVE HYPOTENSION
 Strategy of restricting fluid resuscitation &
permitting a lower than normal perfusion pressure
until the hemorrhage is controlled.
 Strictly time limited (up to 60min maximum)
 European guidance suggests systolic blood
pressure of 80–100mmHg with the exception of
severe Traumatic brain injury, where the mean
arterial pressure should be maintained 80mmHg or
greater.
 Multisystem blunt trauma that occurs in conjunction
with traumatic brain injury management should
focus on achieving adequate cerebral perfusion.

17. HAEMOSTATIC RESUSCITATION:
 Acute traumatic coagulopathy is induced by a
combination of the tissue trauma and shock and is
driven by the degree of tissue hypoperfusion
 The coagulopathy that develops is due to activation
of the protein C pathway, which causes hyper
fibrinolysis.
 Administration of tranexamic acid (1g i.v. bolus and
then 1g infusion over 8h) within 3h of injury has
been shown to be effective

18.  Massive transfusion is defined arbitrarily as either
replacement of more than 50% of a patient's blood
volume within 1h, or replacement of 1–1.5 blood
volumes within a 24-h period.
 Massive transfusion protocol: RCC/FFP/platelets in 1 :
1 : 1 ratio in cases of major hemorrhage.
 Only packed red cell transfusion not recommended.
 High-dose FFP will correct hypofibrinogenaemia and
most coagulation factor deficiencies.
 Cryoprecipitate or fibrinogen concentrate therapy if the
fibrinogen concentration remains less than 1.5g L –1

19.  Platelet concentrate for all instances of severe
thrombocytopenia.
 Calcium chelation by citrate can lead to clinically
significant hypocalcaemia, which should be treated
and monitored.
 Point-of-care coagulation testing (e.g.
thromboelastography (TEG) or rotational
thromboelastometry (RO TEM))

20. PREVENTION OF HYPOTHERMIA:
 Hypothermia causes:
 Platelet dysfunction
 Increased tendency to cardiac arrhythmias
 Left shift of the oxygen–haemoglobin dissociation curve
 Decreases the metabolism of citrate & lactate leading to
metabolic acidosis
 What to do:
 Core temperature measurement
 Warm air over-blankets
 Systems for heating stored blood and allowing rapid
infusion
 All fluids should be warmed to body temperature

21. DAMAGE CONTROL SURGERY
 Lifesaving and temporary procedure for unstable
patients who have sustained major trauma.
 Urgent trauma whole-body CT scanning (with i.v.
contrast) is the gold standard
 Focused assessment with sonography for trauma
(FA S T) scanning by a skilled operator
 Provide decision regarding intervention

22. TRIAGE:
 Systolic blood pressure more than 90 mmHg:
urgent trauma CT
 Systolic blood pressure 70–90 mmHg: senior
decision making; if CT is chosen, the patient MUST
be accompanied by the trauma team
 Systolic blood pressure < 70 mmHg and not
responding: transfer to operating theatre

23. INTERVENTIONAL RADIOLOGY AS AN
ALTERNATIVE TO SURGERY:
 Minimally invasive endovascular techniques to
control hemorrhage by blocking (transcatheter
arterial embolization) or by relining (stent
grafting)bleeding vessels.
 Main objective is to stop the bleeding in parts of the
body that are difficult to access by conventional
surgical means.
 Also prevent the physiological stress that will result
if the patient has to undergo major abdominal or
pelvic exploratory surgery

24. AIMS OF DAMAGE CONTROL SURGERY:
 haemorrhage control (e.g. abdominal packing,
clamps, ligation, splinting of fractures);
 decompression of at risk compartments (i.e. head,
heart,limbs, abdomen);
 to minimise contamination (e.g. debridement of
fractures and wounds, closure or resection of
hollow viscus injuries).

25. TARGETS OF DAMAGE CONTROL RESUSCITATION &
DAMAGE CONTROL SURGERY:
 once haemorrhage has been controlled, the
anaesthetist should be aiming to normalise
physiology by correcting metabolic, fluid and
haemostatic derangements
 normothermia;
 normal pH;
 fibrinogen greater than 1.5 g L–1 normal activated
partial thromboplastin time (APTT) and prothrombin
time (PT);
 normal or improving lactate (a marker of adequacy of
resuscitation); and
 correction of anaemia (haemoglobin 10–11 gd L–1 is
generally accepted).

26.  For patients who do not require immediate surgery
for haemorrhage control, decontamination or
decompression, a team decision may need to be
made whether to proceed to early total care
(definitive treatment of all longbone fractures) or
damage control orthopaedic surgery.
 These decisionsshould be based on an overall
assessment of patient condition, particularly the
trend in blood lactate. I f lactate is less than
2.0mmol L–1, then early total care can be
considered; if more than 2.5mmol L –1, then
continued resuscitation or damage control
orthopaedic surgery is required.