Damage control surgery

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

1. DR BASHIR YUNUS Surgery resident 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 )

13. Stage 1 DCS (skeletal)

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

15. Damage control neurosurgery Arrest intracranial hemorrhage. Evacuate the hematoma. Primary closure of dura to prevent infection. Craniectomy to prevent compartment syndrome.

16. 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

17. 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

18. Indications for definitive surgery Core temperature 36°C or above Correction of acid base balance Normalization of coagulation profile.

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

20. Disadvantages Sepsis and multi organ failure Pneumonia Intra abdominal abscess Enteric fistula Compartment syndrome

21. 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