Current Concepts of Damage Control in Trauma Patients

Juan C Duchesne MD, FACS, FCCP, FCCM Associate Professor of Surgery Medical Director Tulane Surgical Intensive Care Unit Section of Trauma/Critical Care Surgery/Anesthesia/Emergency Medicine Spirit of Charity Hospital, New Orleans Louisiana

Objectives

• • • • •

Outline damage control resuscitation Review the rationale for damage control Results of damage control procedures Outline methods of temporary closure Discuss techniques of definitive closure

TRIANGLE OF DEATH

Acidosis Shock Hypothermia Coagulopathy

Acidosis

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Acidosis correlates with depth of shock and degree of tissue injury.

•

Initial base deficit > - 7.5 = poor prognosis

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Lactate levels > 5 also correlate with a poor outcome but take longer to obtain.

Onset of Coagulopathy

14 12 10 8 2 0 6 4 1 13

93%

Initial 11 6

35%

Subsequent Stone HH, et al: Ann. Surg. 197:532-5, 1983.

Brohi,K et al.: J. Trauma 54:1127-30, 2003.

Lived Died

Hypothermia

100 90 80 70 60 50 40 30 20 10 0 59 41 100 69 40 80 79 70 52 Luna Jurkovich Rutherford

Luna GK, et al:

J. Trauma

27: 1014-1017, 1987.

Jurkovich GJ, et al:

J. Trauma

27:1019-24, 1987.

Rutherford EJ, et al:

Injury

29:605-8, 1998

<32 C <33 C <34 C <35 C <36 C

Phases of Damage Control

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Phase I – Resuscitation in the ED

•

Phase II – Damage Control in the OR

•

Phase III – Stabilization in the ICU

Damage Control in ED – Phase I DON’T SKY DIVE

!

The “Old” Face of Trauma Care Before Damage Control Resuscitation

The “New” Face of Trauma Care with Damage Control Resuscitation

“ You don’t have to swell to be well ” Charity Hospital Trauma Aphorism

Distribution of Trauma patients in NOLA-Blunt (42%), Penetrating (58%) 4.9% of patients had severe injury requiring > 10 U PRBC in 24 hours

Hemostatic / Low Volume Resuscitation (LVR) 1.Hybrid permissive hypotension 2.Minimization of crystalloids 3.LVR with: Hextend and hypertonic saline 4.Close PRBC/ FFP / platelets TRAUMA INDUCED COAGULOPATHY

Combat Data

J TRAUMA 2008

Damage Control in OR – Phase II

• • • • • •

Rapid control of hemorrhage Control of contamination Packing bleeding organs Temporary closure Secondary resuscitation in the ICU Definitive closure after physiologic reserve is restored

Rotondo MF, et al:

J Trauma

1993;35:375-83.

Temporary Closure

• • • •

Skin approximation

–

Towel clips Bogotá bag Modified removable prosthesis Vacuum Assisted Closure (VAC)

Bogotá Bag

• • • • •

Open Abdomen

Advantages Inexpensive Avoids compartment syndrome

• •

Disadvantages Loss of abdominal domain Evisceration Minimizes heat & fluid loss Non-adherent Ease of re-exploration

.

Vacuum Assisted Closure

Vacuum Assisted Closure

• • • •

Advantages Prevent loss of abdominal domain Decreased incidence of Abd. Compartment Syndrome Extend the time of temporary closure Early fascial closure

• •

Disadvantages Requires specialized equipment Cost

Miller PR, et al:

J Trauma

2002;53:843-9.

Operative Damage Control

•

The decision to pursue damage control should be made early based on major physiologic instability due to shock.

•

Damage control procedures should be

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Damage Control in the ICU – Phase III

COAGULOPATHY DEATH TRIAD HYPOTHERMIA ACIDOSIS

ICU CARE

•

Ventilatory Management

•

Secondary Resuscitation

•

Recognition of Complications

– – – –

Abdominal compartment syndrome Dehiscence Abscess Fistula

Abdominal Perfusion Pressure

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APP = MAP – IAP

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Normal > 50 - 60 mm Hg (Critical to perfusion of abdominal organs)

Decompressive Celiotomy

• • •

Rapid decrease in intra-abdominal pressure Rapid decrease in ventilatory requirements Reperfusion syndrome

Definitive Closure

Once the patient has been stabilized and physiologic reserve has been restored, steps should be taken for definitive closure.

Definitive Closure

• • •

Primary closure Biological materials

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Porcine small intestinal submucosa

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Human acellular dermis (Alloderm) Plastic surgery techniques

– – –

Tissue expanders Flaps Component separation

Primary Closure

• •

Advantages Absence of foreign body Decreased risk of infection, enterocutaneous fistula and recurrent wound problems

• •

Disadvantages Increased tension Possible ACS

Biological Materials

• •

Porcine small intestinal submucosa Human acellular dermis (Alloderm)

•

Advantages Ideal for contaminated or infected wounds

• • •

Disadvantages Extremely expensive ($25/cm 2 ) Limited shelf life 4.5% recurrence rate

.

Component Separation

RM RM EO IO TA

Ramirez OM, et al:

Plast Reconstr Surg

1990;86:519-26.

EO IO TA

Component Separation

RM RM EO IO TA

Ramirez OM, et al:

Plast Reconstr Surg

1990;86:519-26.

EO TA IO

Component Separation

EO IO TA RM RM EO IO TA

Ramirez OM, et al

: Plast Reconstr Surg

1990;86:519-26 .

Conclusions

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Trauma-induced coagulopathy (TIC) is associated with increased mortality in trauma patients transfused with > 10U of PRBC during the first few hours after injury.

•

Early hemostatic resuscitation with a ratio of 1:1:1 (FFP : PRBC : Platelets) early after injury improves survival in trauma patients with TIC .

Operative Damage Control

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The decision to pursue damage control should be made early based on major physiologic instability due to shock.

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Damage control procedures should focus on control of bleeding and contamination.

Conclusions

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Damage contol operations can be life saving, but they need to be pursued early and performed rapidly

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Stabilization in the ICU should focus on resuscitating shock and reversing acidosis, coagulopathy, & hypothermia.

Thanks!