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SURGICAL DAMAGE CONTROL. Bradley W. Thomas, MD LCDR MC USN Constanta Trauma Symposium 12 JUNE 2013. OUTLINE. 1. Definition/description 2. Who needs it 3. Operative techniques 4. ICU techniques 5. Reoperation techniques 6. Expected outcome. Navy Definition. “ the capacity of a ship to

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slide1

SURGICAL DAMAGE

CONTROL

Bradley W. Thomas, MD

LCDR MC USN

Constanta Trauma Symposium

12 JUNE 2013

outline

OUTLINE

1. Definition/description

2. Who needs it

3. Operative techniques

4. ICU techniques

5. Reoperation techniques

6. Expected outcome

navy definition

Navy Definition

“the capacity of a ship to

absorb damage and

maintain mission integrity”

Naval War Publication 3-20.31,

Dept Defense, 1996

(c/o Paul Possenti, PA-C,

Bridgeport Hospital)

initial damage control stages
Initial Damage Control Stages

Stage 1: DC1

  • Control hemorrhage
  • Limit peritoneal contamination
  • Temporary abdominal closure

Stage 2: DC2

  • Hypothermia prevention/treatment
  • Correction of coagulopathy
  • Correction of acidosis

Stage 3: DC3

  • Definitive surgery
  • May require multiple surgeries
  • Creation of ostomies, feeding access, fascial closure
  • No longer than 72 hours from Stage 1
  • Data from Rotondo MF, Schwab CW, McGonigal MD, et al. ‘Damage control’: an approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma 1993;35(3):375.
slide6

“Despite the lethality of injuries, if a wounded solider survives the rapid transport to a military medical facility with surgical capability, the likelihood of survival is now higher than any previous recorded conflict.”

Eastridge BJ, Jenkins D, Flaherty S, et al. Trauma system development in

a theater of war: experiences from Operation Iraqi Freedom and Operation

Enduring Freedom. J Trauma 2006;61(6):1366.

who needs damage control intraoperative sequelae of shock
WHO NEEDS DAMAGECONTROL?Intraoperative Sequelae of Shock
  • Initial or persistent hypothermia
  • Initial or persistent metabolic
  • Acidosis
  • Nonmechanical bleeding

* * * * *

  • “metabolic failure”
who needs damage control distinguish between groups

WHO NEEDS DAMAGE CONTROL? DISTINGUISH BETWEEN GROUPS

May Stabilize

Temp 35C

pH > 7.2

BD > -10

Near-Exsanguinated

Temp < 34C

pH < 7.1

BD -15 -20

HR/SBP>0.9

slide10

WHO NEEDS DAMAGE

CONTROL?

Distinguish Between Groups

Near-exsanguinated

Maystabilize

Stophemorrhage

Stophemorrhage

Damagecontrol

Considerdef.

operation

slide12

DAMAGE CONTROL

Control Visceral Hemorrhage

1. Spleen

2. Liver

3. Pancreas

4. Kidney

slide13

DAMAGE CONTROL

Spleen

GradeI-IIGradeIII-IV

Repair→10-15min←Resect

Repair→15-30min

Immunity

suppressed

Immunity

preserved

splenectomy is harmful

SPLENECTOMY IS HARMFUL

  • Lose splenic filter
  • 2. Lose production of
  • 3. Lose immunosuppression

IgM

Tuftsin

Opsonin

Properdin

slide15

DAMAGE CONTROL

Spleen

Surgicel/Avitene/Fibringlue

Suture

Vicrylmeshtamponade

Perisplenicpacking

slide18

DAMAGE CONTROL

Liver

Hasabloodsupplyof

1500ml/min

Therefore,apoorlychosen

damagecontroltechnique

islikelytofailinthe

coagulopathicpatient

slide19

DAMAGE CONTROL

Liver

Compression

Perihepatic packs

Rawsurface

Subc.hematoma

Ballooncathetertamponade→Track

Absorbablemeshtamponade→Fx

slide22

DAMAGE CONTROL

Liver

Moreselective,buttime-consuming

ResectionaldebridementwithS.V.L.

HepatotomywithS.V.L.

hepatic trauma omental pack

HEPATIC TRAUMAOmental Pack

Control intrahepatic venous hemorrhage

Manage dead space

Bring mobile macrophages to site of injury

H.H. Stone, 1975; H.L. Pachter, 1979; T.C. Fabian, 1980

slide29

DAMAGE CONTROL

Pancreas

Controlperipancreaticsmall

bleeders Suture

Controlretropancreaticlarge

bleedersDivide

Deferdistalpancreatectomyto

reoperation

slide31

DAMAGE CONTROL

Kidney

Palpatenormalsizedkidney

onoppositesidebefore

performingneeded

nephrectomy

slide32

DAMAGE CONTROL

Control GI Contamination

Closeholes1layer,suture

IsolateholesUmbilicaltapes

ResectholesStapler

SeverecolonColostomyatreop.

slide34

DAMAGE CONTROL

Control Arterial Hemorrhage

Celiaca.

Sup.mes.a.

Renala.

Ligate

Shunt

Nephrectomy

Iliaca.

Shuntorligate,

fasciotomy,fem-fem

slide36

DAMAGE CONTROL

Control Arterial Hemorrhage

DON’TIGNORELIKELYSEQUELAE

X-clampabd.aorta,CIA,EIA→

Bilateraloripsilateralfasciotomy

slide38

DAMAGE CONTROL

Control Venous Hemorrhage

Commonorexternal,Ligate

iliac, infrarenal, IVC

SMV, Portal

Pelvic Veins

Clamps, Tacks, Omentum

Retrohepaticvenacava

Pack

slide40

DAMAGE CONTROL

Venous Hemorrhage

DON’TIGNORELIKELYSEQUELAE

LigateportalveinorSMV

Silo/NPDandreoperationat12

hours

X-clamporligateinfrarenalIVC

Bilateralfasciotomy

slide42

Managing the Open Abdomen

A simple but eloquent idea

J.Trauma48:201-7,2000

slide46

DAMAGE CONTROL

ICU Phase

Treatment of Hypothermia

Standard Warming maneuvers

Room, Head, Lung, Trunk, IVs

Avoidconduction

Avoidevaporation

Keepbeddry

Keepskindry

slide47

DAMAGE CONTROL

ICU Phase

TREATMENTOF ACIDOSIS

AcidosisuncouplesB-adrenergic

receptorsatcellularlevel

Testdose50-200mEqHC03ifpH<

7.2andpatientfailing

slide48

DAMAGE CONTROL

Reoperation

Removalofpacks/Evaluatehemostasis

*Checkformissedinjuries

CompleteGIresections,repairs,

reconstructionordiversion

Passageofnasojejunalfeedingtube/

Formaljejunostomy

Fascialclosurevs.VAC

slide49

DAMAGE CONTROL

Closure/Coverage Options

1. Components/modified

2. Biologic Mesh

3. Absorbablemesh,delayed

STSG,leaveabighernia

slide52

DAMAGE CONTROL

Complications

1. Ventral Hernia

2. EC Fistula

3. Intraabdominal Abscess

slide53

ABDOMINAL DAMAGE CONTROL

Outcome

56consecutivepatientswithdamage

controllaparotomy:

Mortality

Readmissions

Latemortality

4.4 ±2.2

17/30

27%

76%

0%

Initialops

ICU/LOS

SuttonE:JT61:831,2006

slide54

DAMAGE CONTROL

Summary

1. Choosebasedoncriteria

2. LimitedORtimeusingtechniques

3. SurgeonscontrolICUphase

4. Don’tmissinjuriesatreoperation

alwayspassfeedingtube

5. Expect50-75%survival

slide55

DAMAGE CONTROL

Summary

“….. Advances in surgery are measured by events, and damage control surgery has been one of the greatest advances in trauma surgery in the last 20 years …..”

Hiram C. Polk, M.D.