This document discusses parameters for deciding when to perform damage control surgery. It notes that damage control surgery aims to improve physiology by stopping bleeding, controlling contamination, and transferring patients to the ICU for temporary closure and planned re-exploration. Key indicators for damage control surgery include unstable vital signs like a systolic blood pressure below 90 mmHg, a core temperature below 35°C, coagulopathy, and blood loss requiring over 10 units of packed red blood cells. The document emphasizes the importance of critical thinking and timely decision making in trauma situations.

1. DAMAGE
CONTROL
SURGERY
PARAMETERS TO DECIDE
ESA 2018

2. BRUNO M PEREIRA
MSc, PhD, FACS, FCCM
Prof. Adjunto
Disciplina de Cirurgia do Trauma
UNICAMP
BRUNO M PEREIRA
MSc, PhD, FACS, FCCM
Trauma Surgery Division
UNICAMP
● Acute Care and Trauma Surgery
● Surgical Critical Care
● President – WSACS 2017-2019
● Director – Disasters Committee, SPT (2014-2016)
Prof. Dr.
Nothing to disclose

3. DAMAGE
CONTROL
WHEN TO INDICATE ?
EASY QUESTION ?

4. WHERE TO GO
ON THE RIGHT
MOMENT?

5. NO CONSENSUS
BAD NEWS !!!!
MAY BE WE SHOULD START WITH VITAL SIGNS

6. DAMAGE CONTROL
CONCEPT
● Physiology consumption – no physiologic reserve anymore
● Restore patient physiology
● Stop bleeding, Control Contamination, ICU
● Temporary closure and planned re-exploration

7. DAMAGE CONTROL
Resuscitation

8. Di Saverio et al in: Trauma Surgery, Vol 1, 2014, Chapter III, Springer, USA.
BUT ONCE PRESENT IT MAY BE TOO LATE

9. TEAM COMUNICATION
IS ESSENTIAL

10. WHAT THE EVIDENCE
SHOWS?arrest, April 2012
● SBP/ BE – 7.5 / Core Temp <35.5˚C. Matsumoto et al, 2010
● Mechanism of Trauma. Parreira et al, 2002
● Blood loss and PRBC transfusion. Asensio et al, 2001
● Coagulopathy. Cosgriff et al, 1997
● Number of lap pads used on surgery, Garrison et al, 1996
LITERATURE

11. SUMMARY
SOME EVIDENCES FROM LAST PUBLICATIONS
Author
Year
Garrison
1996
Cosgriff
1997
Rotondo
1997
Asensio
2001
Parreira
2002
Germanos
2008
Matsumoto
2010
Design (N)
Prospec
(N=70)
Prospec
(N=58)
Review Prospec
(N=548)
Prospec
(N=74)
Review SR/ MA
(N=34)
Indication
Criteria
Number
of Lap
Pads used
on surgery
Predictive
values of
coagulopa-
thy
- ≥ 2 L BL
or
≥ 1.5 L
PRBC
Shock,
Mechnism
of injury
- Shock,
Mechnism of
injury
SBP/ Temp
≤ 90
mmHg/ -
≤ 70 mmHg
< 34˚C
- / - - / ≤ 34˚C - / < 110
mmHg
< 70 mmHg
≤ 34˚C
≤ 90 mmHg
≤ 35.5˚C
pH/ BE
< 7.2 / - < 7.1 / - < 7.3 / - < 7.2 / < `-
12 mEqL
< 7.25 / < -
10 mEqL
< 7.2 / - - / < -7.5
Blood
alterations
> 15 PRBC Coagulopa-
thy
>10 PRBC
4L lost
> 12 PRBC
5L lost
Persistent
Shock
> 10 PRBC
Persistent
Shock
-

12. ● Specific method for Trauma
● Major Objectives:
o Improve physiology
o Stop the Bleeding
o Control Contamination
● Decide:
o Damage Control vs Definitive Treatment
DAMAGE
CONTROL
REMEMBER
● Select the correct patient

14. ● Take it as soon as possible
● Recognize “trauma glues”
● Remember on physiology
● Chat with your team
CRITICAL
DECISION

15. TIPS
IMPORTANT
● Pay attention on HOSTILE physiology
o Check ABG’s
o Edema of bowel mucosa
o Midgut distension
o Dusky serosal surface
o Tissue cold on touch
o Non-compliant swollen abdominal wall
o Diffuse oozing from surgical incisions
IF YOU’RE YET TO TAKE A CRITICAL DECISION…

16. OPERATING ?
STILL
IT IS TIME TO BAIL OUT!!!
● Injury PATTERNS indicating the need for BAIL OUT
o Combined major vascular and hollow visceral
injuries
o Penetrating injury to the “surgical soul”
o High grade liver injury
o Pelvic fracture with an expanding pelvic hematoma
o Injuries requiring surgery in other cavities (chest,
head, neck)

17. IT IS ALL ABOUT CRITICAL THINKING
● Critical thinking is based on evidence and logical
reasoning. Emotions and memorization are not a part
of logical thinking
● Critical thinking requires evaluating and improving your
own thought processes. It relies on universal
intellectual values like clarity, relevance and
consistency
KEY POINT
IMPORTANT

18. ● Improved cognitive skills
● A foundation of logical decision
making on which you can draw, even
in stressful situations; and,
● Higher academic and professional
achievement
POSITIVE
CRITICAL THINKING
EFFECTS

19. ● Critical thinking forces intellectual self improvement
● Critical thinking allows you to become a better team player
● Critical thinking leads to a more creative mindset
● Critical thinking helps you stay calm and rational under
stress
● Think about the impact critical thinking skills can have in
your context
CRITICAL THINKING
AND DECISION MAKING

20. VALID FOR THE ENTIRE
TEAM

21. ON TRAUMA
SIMULATION
Lack of critical thinking
and decision making
is often observed

22. Campinas, Brazil – 29th May – 01st June 2019

23. BRUNO M PEREIRA
MSc, PhD, FACS, FCCM
Dr.bruno@gruposurgical.com.br