Damage Control Approach

DAMAGE CONTROL
APPROACH
Usama Saeed
House Surgeon, Surgical Unit I
SIMS/Services Hospital, Lahore

 Definition
 Concept of Damage control
 Principles/Lethal Triad
 Indications of Damage Control
 Damage Control Sequence
 Complications
 Summary
Outline :

Definition:
 Damage control surgery (DCS) is a form of surgery typically done by trauma
surgeons utilized in severe unstable injuries.
DCS is a treatment strategy of temporization; prioritizing physiological recovery over
anatomical repair. Its use is associated with dramatically increased survival of the
most seriously injured patients.
 Damage control resuscitation (DCR) is a newer development within the damage
control paradigm, and describes novel resuscitation strategies aimed to limit the
physiological derangement of trauma patients.

 “ …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 ?


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

Why Damage Control?
“It is better to cure in more phases than to kill in
one …”

Principles:
 Lethal Triad:
 Acidosis, Hypothermia and Coagulopathy
 Damage Control Resuscitation (DCR)
 Novel resuscitative strategies to limit
physiological derangement
 Damage Control Surgery (DCS)
 Treatment strategy of TEMPORIZATION by
prioritizing Physiological Recovery before
Anatomical Repair
Four phase strategy
 DC0: DCR, RSI, early rewarming and
expedient transport to OR
 DC1: Concurrent DCR and DCS
 DC2: ICU resuscitation and
stabilization
 DC3: Definitive surgery

Hypothermia
1. Heat loss by evaporation and conduction
2. Inability to generate heat
Central cause of all derangements.
 Normal human body temperature is 35.6–37.8 degrees C with hypothermia being
defined as a core temperature < 35 degrees
 The coagulation system is a temperature- and pH-dependent series of complex
enzymatic reactions.
 As the patient’s core temperature decreases, so does the body’s ability to stop
bleeding. This is a result of impaired platelet function, inhibition of the clotting
factors, and inappropriate activation of clot breakdown.

Metabolic acidosis
 Healthy individual maintains a physiologically normal pH of 7.35–7.45 . Acidosis
is defined as an arterial pH < 7.35
 In trauma patients the major contributor is poor perfusion to the tissues. Acute
blood loss, peripheral vasoconstriction and low cardiac output impair oxygen
delivery to the tissues. Anaerobic system is activated in return and lactic acidosis
produced.
 Additional cause of acidosis in the trauma patient is excessive resuscitation using
unbalanced crystalloid solutions such as normal saline (pH 5.5)
 Another harmful effects of acidemia is that coagulation system can become
severely impaired. In one study, the function of coagulation system was reduced
by 55–70% when the pH dropped from 7.4 to 7.0.

Coagulopathy
 Consumption dilution
Dilutional coagulopathy occurs when we resuscitate a bleeding trauma patient
with fluid or blood products that don’t contain the same clotting factors.
 Hemorrhage
 Hypothermia
 Acidosis

Indications:
 Massive Blood Transfusion
 >10 unit PRBC
 Severe Metabolic Acidosis
 pH< 7.30
 Hypothermia
 <35 degree C
 Operative time
 >90 mins
 Coagulopathy
 Either on lab results or ‘non surgical’ bleeding
 Lactate
 >5 mmol/L

STANDARD SURGICAL APPROACH
DAMAGE CONTROL APPROACH
- pH below 7.2
- Core temperature below 32/ 34 C
- More than 5 transfusion
?
Do not wait !!

DC0: DCR / Rapid assessment
 Extends from pre-hospital setting to ER
 DCR
 Consist of
 <C>ABC (RSI)
 Permissive hypotension
 Limitation of crystalloid and early
transfusion
 Early use of TXA
 Gaining large bore IV access
 Prevention of hypothermia
 Rapid assessment of trauma
 Expedient transport to OR
 Early use of Blood and Blood products
 Massive transfusion protocol
 Prevent delay in accessing blood
 Imaging
 RSI f/b chest x-rays
 Pelvic binder
 If stabilized CT scan
 Primary and secondary surveys

DC1: Concurrent DCR and DCS
 Objectives
 Hemorrhage control
 Limitation of contamination
 Temporary abdominal closure
 Preparation
 OT prepped before taking patient
 Cruciform position
 Prepped from chin to mid thigh
 NG, Foley
 Don’t delay for central line
 Incision
 Midline laparotomy
Incision should be made
from Xiphoid to Pubis.

DC1 cont…
 Hemorrhage control:
 Large clots removed manually. Only
expanding hematomas require evacuation.
 Non-expanding should not be touched and
may be treated with packing.
 Retract and pack each quadrant
sequentially.
 Vessels which cannot be ligated without
loss of life or limb can be treated with
temporary indwelling shunts.
 If there is continued haemorrhage with packs
in place, aortic control may be necessary.

DC1 cont…
 Hemorrhage control:
 Solid organ injuries:
 Prolonged repair to be avoided
 Splenic, Renal and Pancreatic injuries
best by partial or total resection
 Liver bleeding is managed by Peri-
hepatic packing and tropical hemostatic
agents.
 Consider angio-embolization whenever
available

DC1 cont…
 Abdominal closure:
 Fascial closure not
recommended
 Temporary closure to avoid
IAH/ACS
 Abdominal packing:
sufficient to provide
tamponade but not
impeding vascular return or
arterial supply.
 Contamination control:
 Control spillage of intestinal content and
urine.
 Simple bowel perforation in limited number
may be repaired, else resection.
 Reconstruction, stoma creation and feeding
tube avoided.
 Biliary/ Pancreatic duct injury: controlled
fistula.
 Bladder injury: Primary suturing with foley
drainage.

DC2: ICU resuscitation and stabilization
 Goal:
 Reverse hypotension related metabolic
failure
 Support physiological and biochemical
restoration
 Normalize lactate within 24 hrs
 Aggressive Core Rewarming
 Improves perfusion and reverses
coagulopathy.
 Passive and Active techniques
 Correct Coagulopathy
 FFP, Platelets and Cryoprecipitate
 Complete physical examination
and relevant imaging
 Repair planning
 Usually require 24 to 36 Hrs
 Unplanned re-operation:
 Ongoing transfusion despite
normal clotting and core temp.
 ACS: sustained or repeated IAP
>20 mm Hg + new
single/multiple organ failure

DC3: Definitive surgery
 Maximum impact on achieving successful
outcome
 Normothermic, normal coagulation, pH and
lactate (24 – 36 Hrs)
 Operative game plan
 Handover (if different surgeon)
 Irrigate packs to avoid clot disruption
 Complete re-examination and definitive
repair
 Additional sites of bleeding controlled,
vascular repairs done and intestinal
continuity is restored.
 Abdominal closure
 Formal abdominal closure
without tension should be
done.
 If airway pressure >10 cm H2O
temporary closure to be done
 Can be closed within 1 week

COMPLICATIONS OF DCS:
 Expected complication rate from damage control ranges from 25% to 40%.
 Failure to recognize Non-coagulopathic hemorrhage which leads to exsanguination.
 Abdominal compartmental syndrome which leads to multi organ failure.
 Formation of enteric fistulas esp. in pts with M.O.F and open abdomens for a long
time,
 ARDS, intra-abdominal abscesses, sepsis
 Mortality at 60%.

 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

Damage Control Approach

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Damage Control Approach