Damage Control Resuscitation.

Damage Control Resuscitation
By
DR. Mahmoud Abdulkareem
M.S {Cairo} , FRCS {Glasgow}
Consultant Surgeon,
King Fahad Specialist Hospital
Sunday, October 26, 2014 2

History of Trauma Resuscitation
About fifty years ago; there was Little or
no systematic resuscitation after a
civilian injury.

THE NEED FOR TRAUMA SYSTEMS—
HISTORY…. cont.
“the neglected disease of
modern society.”
National Research Council: Accidental Death and Disability: The Neglected Disease of Modern
Society. Washington, DC: U.S. Government Printing Office, 1966.

MODERN TRAUMA SYSTEM
DEVELOPMENT…. cont.
By 1975, Germany had established a
nationwide trauma system, so that no
patient was more than 15–20 minutes
from one of these regional canters.

Injury
prevention
has
become
an
essential
focus for
all trauma
systems
prevention

Trauma system
The true value of a trauma system is
derived from the seamless transition
between each phase of care

Trauma Management: Golden Hour
Golden Hour
Time to reach operating room (or other definitive treatment)
Patients in their Golden Hour must
 Be recognized quickly
 Have only immediate life threats managed
Be transported to an appropriate facility
Survival depends on assessment skills
Good assessment results from
An organized approach
Clearly defined priorities
Understanding available resources

Prehospital Care ….con.
The goal is to get the
right patient to the
right hospital
at the
right time for
definitive care

Early hospital phase:
Advanced life support is provided
[by an organized trauma team]

Trauma Team
Definition
The trauma team is an organized group of professionals who perform initial assessment and
resuscitation of critically injured patients. Team composition, level of response, and
responsibilities of each member are institution-specific. Personnel are outlined as follows:
1. Trauma surgeon—a general surgeon with demonstrated training and interest in trauma care. In
designated trauma centers, the trauma surgeon typically functions as the trauma team leader.
2. Emergency medicine physician—in many hospitals, the emergency medicine physician functions as
the trauma team leader depending on the perceived severity of injuries. Ideally, these physicians
have Advanced Trauma Life Support (ATLS) certification.
3. Anesthesiologist—a physician with special skills in airway management, sedation, and analgesia.
In many trauma centers, this role may be fulfilled by a certified registered nurse anesthetist
4. Trauma nurses—emergency department nurses with specialized training and demonstrated
interest in trauma care.
5. Resident physicians—residents in emergency medicine or surgery and trauma fellows may assume
active roles in the trauma team. In Level I and II trauma centers, senior surgical residents and
trauma fellows may function as trauma team leaders.
6. Respiratory therapist—therapist available to assist in the evaluation and management of the
patient's respiratory status.
7. Radiology technicians—technicians available to obtain x-rays as indicated by the initial assessment
and secondary survey.
8. Surgical subspecialists—although not typically involved in the initial assessment, surgical
consultants (e.g., orthopedic surgeons, neurosurgeons) are vital members of the trauma team.
9. Other personnel—the trauma team may also include OR nurses, laboratory technicians, ECG
technicians, chaplains, social workers, transport personnel, and case managers.

Original article
Impact of a multifunctional image-guided therapy suite
on emergency multiple trauma care
T. Gross1, P. Messmer1,7, F. Amsler5, I. Fu¨ glistaler-Montali1, M. Zu¨ rcher2, R. W. Hu¨ gli1,6,
P. Regazzoni1,3 and A. L. Jacob1,4
British Journal of Surgery 2010; 97: 118–127
Conclusion: Implementation of a MIGTS in the emergency treatment of multiple trauma significantly
accelerated the procedure and reduced the number of in-hospital transports.

Posttraumatic hemorrhage is responsible for
one of the leading causes of preventable
human deaths worldwide.

INTRODUCTION
During the last two decades, advances in pre-hospital
care and the adoption of the “scoop
and run” philosophy has resulted in the arrival
of more severely injured patients who typically
might have died in the field or en route to the
hospital.

Standard surgical practice
Standard surgical practice (early total care.
The best operation for a patient is one,
definitive procedure
The first chance of any surgical intervention
is the best chance for any definitive repair or
reconstruction
ER
OR ICU

What has been going on??
The conventional sequence of the management
of trauma surgery was to bring the patient to
the operating room after initial resuscitation
and then to operate for complete repair of the
injuries. Subsequently, these patients were
sent to the intensive care unit where a good
number of them succumbed due to metabolic
derangement of the body.

The outcome…..
“The operation was a success but the
patient died anyway”–
4/21/14 23
Anonymous

But,…… why?!
In severe trauma patients a triad of
hypothermia, metabolic acidosis, and
coagulopathy rapidly established. This so
called " vicious cycle of metabolic failure " is
irreversible as long as patient is in the
operating room with the abdomen open
during a prolonged procedure.

" vicious cycle of metabolic failure "

Damage control
Damage control is a naval term first used
during World War II to describe emergency
measures for control of flooding that
threatens to sink a ship. A range of simple
procedures may be used, but the central
goal is to ensure survival of the ship until it
reaches a port where definitive repairs can
be safely performed.

Damage Control !

Damage Control – Philosophy
Damage control is based on the principal
that outcome after major trauma is
determined by the physiological limits of
the patient , rather than by the effort of
anatomical restoration by the surgeon.

Applying the same philosophy
To save the patients in extremis, surgery should
be abbreviated . only immediately life
threatening injuries should be attended and
repaired, while other injuries should be
temporized and repaired definitively when the
patient is more stable. The best place for a
severely and multiply injured patient is in the
intensive care unit.

Damage Control – Philosophy
The damage control concept places
surgery as an integral part of the
resuscitative process, rather than an
end in itself.

The term “Damage control”
Rotondo and Schwab in 1992 coined the term “damage
control” and outlined a three phased approach:
Part one (DC I) consists of immediate exploratory laparotomy
with control of bleeding and contamination, abdominal
packing and abbreviated wound closure.
Part two (DC II) consists of the ICU resuscitation; immediate
endpoints include physiological and biochemical stabilization.
A tertiary exam should be performed at this time to identify
all injuries.
Part three (DC III) consists of re-exploration and definitive
repair of all injuries.

Damage Control Surgery
The later damage control is
applied, the less successful the
outcome.

When to employ damage control
ο Use damage control in patients who are present
with or at risk for developing:
♦ Multiple life-threatening injuries.
♦ Acidosis (pH < 7.2).
♦ Hypothermia (temp < 34°C).
♦ Hypotension and shock on presentation.
♦ Combined hollow viscus and vascular or
vascularized organ injury.
♦ Coagulopathy (PT > 19 sec and/or PTT > 60 sec).
♦ Mass casualty situation.
ο

REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta),
together with a pelvic binder, for control of hemorrhage in ER

REBOA (Resuscitative Endovascular
Balloon Occlusion of the Aorta)

Phase 1 of damage control includes 5 distinct steps:
1. Control of hemorrhage.
4/21/14 44

1. Control of hemorrhage
intra-arterial shunt in left common iliac artery
4/21/14 45

2. Control of contamination.
In this case, especially with colonic
injuries, or multiple small bowel lesions,
it is wiser to resect non-viable bowel and
close the ends, leaving them in the
abdomen for anastomosis at the second
procedure. The linear stapler is useful to
achieve this, but bowel ends may be
closed with running suture or even
umbilical tapes. Ileostomies or
colostomies should preferably not be
performed in a damage control setting,
especially if the abdomen is to be left
open, as control of spillage is almost
impossible.
4/21/14 46

3- EXPLORATION TO R/O SIGNIFICANT INJURY

4-Therapuitic packing
4/21/14 48

Extraperitoneal Packing
Directly to the IS- joint
Packing of the fractured area
Laparotomy pads into the true pelvis

5- Temporary abdominal closure .
Left lateral thoracotomy with towel clip closure of damage-control celiotomy.
Courtesy of Pedro Gustavo R. Teixeira, Trauma Surgeon, Brazil, The Trauma Imagebank.

Methods of Temporary abdominal closure
Bogota bag

Damage Control Resuscitation
in Combination With Damage
Control Laparotomy : A Survival Advantage
Approach :
1. Permissive Hypotension
2. Limited Crystalloid
3. Transfuse Blood Components in Equal Ratios
PRBC’s / FFP / Platelets
Source Control of Bleeding
J Trauma. 2010;69: 46–52

Damage control resuscitation (DCR) represents the natural
evolution of the initial concept of damage control surgery.

Permissive Hypotension in Trauma Resus.
IV fluids in hypovolemic shock:
• No  survival, some  mortality
Theories on IVF in trauma:
1. BP dislodges clots
2. BP =  bleeding
3.IVF hemodilutes clotting factors
Duchesne JC et al. Damage Control Resuscitation: From Emergency Department to the
Operating Room. The Amer Surgeon. 2011; 77: 201-206.

Permissive Hypotension Limits
• SBP 90 (MAP 50 – 60 mmHg):
• Ideal permissive hypotension < 90 min.
• Severe damage when > 120 min.
• It is important to remember that
permissive hypotension is a
temporizing measure to improve
outcomes until the source of bleeding is
controlled.
Li T, et al. Ideal Permissive Hypotension to Resuscitate Uncontrolled Hemorrhagic Shock and
the Tolerance Time in Rats. Anesthesiology. 2011; 114 (1): 111-119.

Contraindication of Permissive
Hypotension
• traumatic brain injuries, because adequate
perfusion pressure is crucial to ensure tissue
oxygenation of the central nervous system.
• Preexisting conditions such as hypertension,
angina pectoris, coronary disease, and carotid
stenosis may also lead to severe cardiovascular
dysfunction when trauma patients are
hypotensive. These conditions are common
mainly in the elderly (>65 years old), but also
occur in other age groups because of occult
disease.

Hemostatic Resuscitation
The concept of giving plasma and platelets early
along with red cells in an attempt to closely
approximate whole blood makes a lot of sense. In
fact, when we reviewed blood usage at the Shock
Trauma Center in the year 2000, massively
transfused patients ultimately received a unit of
plasma for every unit of blood that was transfused.
It made a lot of sense that giving FFP earlier would
be beneficial.

Hemostatic resuscitation is a transfusion
strategy that targets coagulopathy with early
blood product administration.
Hemostatic resuscitation, which promotes balanced
blood product transfusion ratios while minimizing
crystalloid infusion, improves outcome in critically
injured, coagulopathic adults.

The new resuscitative paradigm has
become to allow a systolic blood
pressure to be around 80 mmHg, to
limit crystalloid resuscitation, and use
blood, FFP and platelets in a one to one
to one ratio.

Disclaiming and Criticizing Hemostatic Resuscitation
with 1:1:1 ratios
DCR, which in part aims to reproduce whole blood
resuscitation via the use of approximately 1:1:1 ratios of
red blood cells (RBCs), plasma, and platelets, has become
the standard of care for the transfusion management of
patients with severe hemorrhage. This approach,
however, comes with a potential cost: the use of a
greater quantities of plasma and platelets.

CAGS AND ACS EVIDENCE BASED REVIEWS IN SURGERY. 50
Is early transfusion of plasma and platelets in higher ratios associated
with decreased in-hospital mortality in bleeding patients?
While the PROMMTT study adds further evidence to
support transfusions with higher plasma :RBC
transfusions, further studies are needed, especially
regarding how to efficiently identify the patients who will
benefit from early administration of the therapy.
J can chir, Vol. 57, No 5, octobre 2014
© 2014 Association médicale canadienne

Acute Traumatic Coagulopathy
Recent studies have shown that nearly 25% of trauma patients
present with a clinically significant coagulopathy upon arrival
in the emergency department which affects their overall
outcome.4 Interestingly, this early coagulopathy occurred
before any significant consumption or fluid administration and
in the absence of a relevant acidaemia or hypothermia.
Br. J. Anaesth. (2010) 105 (2): 103-105.

 Recognized in patients with significant tissue
injury and hypotension
 Distinct from iatrogenic coagulopathy after
trauma
 Dilutional coagulopathy
 Present prior to resuscitation in rapidly evacuated
severe trauma
 Mortality rate increased 4x
 Modulated through protein C activation

The anticoagulant thrombomodulin protein C pathway is overtly
activated, resulting in reduced pro-coagulatory potential and
increased fibrinolytic activity. Once protein C is activated through a
thrombin–thrombotic-dependent reaction, activated protein C
(aPC) exerts its profound anticoagulant effects by irreversibly
inactivating factors Va and VIIIa. In addition to its direct inhibition
of fibrin formation, aPC causes resolution of formed clots by
stopping the inhibition of fibrinolysis by direct inhibition of
plasminogen activator inhibitor .

Hemostasis
Hemostasis is a complex physiologic process
involving many constituents that act in symphony
to form a clot. Conventional coagulation tests,
such as prothrombin time (PT), international
normalized ratio (INR), activated partial
thromboplastin time (aPTT), fibrinogen
concentration, and platelet count, measure only a
fraction of this process. Moreover, these tests
sometimes lack accuracy in trauma settings.

Viscoelastic Hemostatic Assays (VHA),
In recent years, viscoelastic hemostatic assays (VHA), including
thrombelastography (TEG) and thrombelastometry, have been
demonstrated to be ideal methods of monitoring coagulation
function in trauma patients . Furthermore, several studies have
suggested the potential of VHA tests to guide component blood
transfusion in a variety of patient groups . In particular, a recent
study by Kashuk et al. showed that goal-directed transfusion
based on rapid TEG was useful in managing trauma-induced
coagulopathy, with the potential to reduce blood product
administration in trauma patients.

Viscoelastic Hemostatic Assays (VHA),
Specifically, TEG depicts the following four stages of clot formation:
(1) initiation, (2) amplification, (3) propagation, and (4) termination through
fibrinolysis. This is accomplished by placing a 0.36 mL aliquot of citrated
whole blood sample into a Kaolin coated (“standard”) TEG cup that has been
pre-warmed to 37°C. A pin, attached by a wire to a transducer, is then
suspended into the sample. The cup rotates around the pin within the TEG
autoanalyzer at an angle of 4.45 degrees every 10 seconds. As the clot forms,
the pin and the cup are ultimately joined by the formation of the fibrin and
platelet clot. This causes the pin and the cup to rotate together, with the
resultant change in tension detected by the transducer. A graphical output is
then plotted as a change in tension (measured in millimeters on the y axis)
versus time (measured in minutes on the x-axis).
The four key parameters of the TEG tracing are the: (1) r value (reaction time
to clot formation), (2) α (alpha) angle – rate of clot formation, (3) MA
(maximum amplitude – maximum strength of clot), and (4) LY30 (percent clot
lysis 30 minutes after the MA).

Normal TEG tracing (in black) resembles a wide flat (non-functional)
shovel with a short handle. The superimposed “shovel” (in red)
demonstrates a tracing with a prolonged r, flat α angle, small MA, and
increased LY 30, indicative of a systemic coagulopathy with fibrinolysis.

Abnormal TEM Tracings, Interventions

Antifibrinolytic componds
• Tranexamic acid (TXA)
– Binds to plasminogen
– Interferes with the conversion to plasmin
– Inhibits fibrinolysis
• Diminishes blood loss.

How and When to Use TXA for Trauma Patients
Indications:
Adults with acute traumatic injury leading to significant
hemorrhage and requiring blood transfusion.
May be beneficial in trauma patients with significant hemorrhage
and evidence of hyperfibrinolysis on rotational
electrothromboelastometry (ROTEM).
Should only be given less than 3 hours from the time of injury.
Dosing: 1 gram IV bolus over 10 minutes, followed by 1 gram
continuous IV infusion over 8 hours.

وآخر دعوانا أن الحمد لله رب العالمين.
10/26/2014

Damage Control Resuscitation.

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