Damage control surgery

Section: Trauma Curriculum: Curriculum, page 75

Overview

• What is damage control and what are the principles?
  • A deliberate and pre-emptive set of non-traditional maneuvers used to reverse the pre-terminal effect of exsanguination, massive injury and shock
  • Goal is to temporize management of major injuries with directed resuscitation and staged surgery, to allow for the resuscitation and restoration of normal physiology
• What is permissive hypotension and why is it a target?
  • Resuscitation goal of organ perfusion rather than normotension
  • SBP > 80 or MAP > 90 in severe head injury
  • Minimises blood loss by accepting a lower but adequate systolic blood pressure for organ perfusion, at a time where bleeding is occurring and has not yet been definitively managed
• Why is temporary abdominal closure used?
  • Prevent heat and moisture loss and protect the abdominal viscera
  • Reduce the risk of abdominal compartment syndrome in a patient that is likely to have received a large amount of IVF resuscitation and undergo tissue interstitial oedema
  • Difficulty or inability to close the abdomen due to point B
  • Damage control surgery has taken place and a relook procedure is required
    • Stapled off bowel ends
    • Packs in place for haemorrhage control
    • Vascular shunts created for named vessels requiring definitive repair
• What is a planned hernia and why is it made?
  • Closure of the skin of the abdominal wall over intra-abdominal contents with the fascia remaining open
  • Inability to reapproximate the retracted abdominal wall edges
  • Sizeable tissue defect
  • Risk of tertiary abdominal compartment syndrome
  • Inadequate infection source control
  • Anterior enteric fistula
  • Poor nutritional status

Pathophysiology

• Hypothermia
  • Why does it occur
    • Exposure at scene
    • Fluid resus with cool fluids
    • Blood loss
    • Inadequate heat production from decreased cellular perfusion and oxygenation
  • Effect
    • Exacerbates coagulopathy
    • Alters homeostasis
• Acidosis
  • Anaerobic respiration (hypoxia) due to poor tissue perfusion and oxygenation
  • Metabolic lactic acidosis
  • Acidosis promotes coagulopathy
• Coagulopathy
  • Hypothermia, Acidosis and Haemodilution during resuscitation
  • Factors used up, lost or diluted

Damage Control Resuscitation

• Definition
  • Proactive, anticipatory treatment of the lethal triad which presents with critical injury and shock
• Components
  • Permissive hypotension (Hypotensive resuscitation)
    • Benefits
      • Reduces blood loss
      • Reduces need for additional fluids
        • Which may cause dilutional coagulopathy
        • Thus avoids acidosis, hypothermia and coagulopathy
    • Definition
      • Strategy to reduce blood loss by limiting systolic BP to the minimum required to maintain vital organ perfusion
    • Target
      • SBP 80 (severe head trauma MAP > 80)
    • Rationale
      • High BP with uncontrolled bleeding leads to clots popping off
  • Minimize crystalloids and give blood products early → MTP
    • 1:1:1
    • Improved survival
    • By avoiding lethal triad
      • Acidosis - avoids lactic acidosis from anaerobic respiration by dilution of blood present with crystalloid
      • Hypothermia - avoided by giving crystalloid that is cooler than blood
  • Goal directed haemostasis - TEG/ROTEM
  • Targeting hypothermia
    • Can lead to SSI post laparotomy
    • Feeds acidosis

Damage Control Surgery

• Definition
  • Minimization of operative time and surgical intervention in the unstable patient by focusing purely on bleeding and contamination temporary control
• Goal
  • Minimize the impact of the lethal triad by minimizing operative time to allow quick transfer to critical care for physiology restoration
• 5 Stages
  • 1 - Patient selection
  • 2 - Operative haemorrhage and contamination control
  • 3 - Physiological restoration in ICU
  • 4 - Definitive surgery
  • 5 - Abdominal wall closure
• Patient Selection:
  • Unstable patients on MTP with lethal triad
  • H/D unstable and non-responsive to fluids
  • MTP
  • Hypothermic
  • Acidotic
  • Coagulopathic
  • Surgically challenging
    • Complex major or multiple injuries requiring time to repair definitively
• Operative Haemorrhage and Contamination Control
  • Packing/shunts/resuscitative endovascular balloon aortic occlusion (REBOA)
  • Intravascular shunts (temporary)
  • Stapled off bowel ends/T-tubes etc
• Physiological Restoration in ICU
  • Lethal triad → Noting the acidosis is fixed with improving tissue perfusion
    • Acidotic due to lactic acidosis from anaerobic respiration because functional oxygen is inadequate
  • Parameters to look at
    • Lactate - improved
    • Mixed venous oxygen → blood gas
    • UO
    • H/D
    • Acidaemia reduction
    • Reduction in inotropic support with adequate volume repletion
  • Monitor for compartment syndrome
  • Tertiary survey
• Definitive Surgery
  • Once metabolically up for it
  • Relook laparotomy
• Abdominal Wall Closure
  • Delayed primary closure
  • Planned hernia
• Damage Control Orthopaedics
  • Goals
    • Limit ongoing haemorrhage through effective # stabilization
    • Minimizing additional physiological insult
  • What it involves
    • External fixation - long bones/pelvis
    • Wound washouts
    • Excision of devitalised tissues
    • Fasciotomy