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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

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current concepts of damage control in trauma patients
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
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
TRIANGLE OF DEATH

Acidosis

Hypothermia Coagulopathy

Shock

acidosis
Acidosis

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

Initial base deficit > - 7.5 = poor prognosis

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

onset of coagulopathy
Onset of Coagulopathy

93%

35%

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

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

hypothermia
Hypothermia

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

phases of damage control
Phases of Damage Control

Phase I – Resuscitation in the ED

Phase II – Damage Control in the OR

Phase III – Stabilization in the ICU

slide10

The “Old” Face of Trauma Care

Before Damage Control Resuscitation

you don t have to swell to be well charity hospital trauma aphorism
“You don’t have to swell to be well” Charity Hospital Trauma Aphorism
slide13

Distribution of Trauma patients in NOLA-Blunt (42%), Penetrating (58%)

4.9% of patients had severe injury requiring > 10 U PRBC in 24 hours

slide14

Hemostatic / Low Volume Resuscitation (LVR)

  • Hybrid permissive hypotension
  • Minimization of crystalloids
  • LVR with: Hextend and hypertonic saline
  • Close PRBC/ FFP / platelets

TRAUMA INDUCED COAGULOPATHY

damage control in or phase ii
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
Temporary Closure
  • Skin approximation
    • Towel clips
  • Bogotá bag
  • Modified removable prosthesis
  • Vacuum Assisted Closure (VAC)
slide20
Advantages

Inexpensive

Avoids compartment syndrome

Minimizes heat & fluid loss

Non-adherent

Ease of re-exploration

Disadvantages

Loss of abdominal domain

Evisceration

Open Abdomen

.

vacuum assisted closure
Vacuum AssistedClosure

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
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

rapid (i.e., 30 to 45 minutes).

?????

slide24

Damage Control in the ICU – Phase III

DEATH TRIAD

ACIDOSIS

COAGULOPATHY

HYPOTHERMIA

icu care
ICU CARE
  • Ventilatory Management
  • Secondary Resuscitation
  • Recognition of Complications
    • Abdominal compartment syndrome
    • Dehiscence
    • Abscess
    • Fistula
abdominal perfusion pressure
Abdominal Perfusion Pressure
  • APP = MAP – IAP
  • 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

Decompressive Celiotomy
definitive closure
Definitive Closure

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

definitive closure1
Definitive Closure
  • Primary closure
  • Biological materials
    • Porcine small intestinal submucosa
    • 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

Primary Closure
biological materials
Advantages

Ideal for contaminated or infected wounds

Disadvantages

Extremely expensive ($25/cm2)

Limited shelf life

4.5% recurrence rate

Biological Materials
  • Porcine small intestinal submucosa
  • Human acellular dermis (Alloderm)

.

slide32

Component Separation

RM

RM

EO

EO

IO

IO

TA

TA

Ramirez OM, et al: Plast Reconstr Surg 1990;86:519-26.

slide33

Component Separation

RM

RM

EO

IO

EO

TA

IO

TA

Ramirez OM, et al: Plast Reconstr Surg 1990;86:519-26.

component separation
Component Separation

Ramirez OM, et al: PlastReconstrSurg1990;86:519-26.

conclusions
Conclusions
  • 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 control1
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 focus

on control of bleeding and contamination.

conclusions1
Conclusions
  • Damage contol operations can be life- saving, but they need to be pursued early and performed rapidly
  • Stabilization in the ICU should focus on resuscitating shock and reversing acidosis, coagulopathy, & hypothermia.