D R B A S H I R Y U N U S

S U R G E R Y R E S I D E N T

DAMAGE CONTROL SURGERY

INTRODUCTION

• A form of surgery by trauma surgeons for critically

traumatized patient to stabilize the injuries, targeted

at prevention of the triad of death (Hypothermia,

acidosis and coagulopathy) rather than the

correction of anatomy.

DEFINITION

• Damage control surgery is defined as the

rapid initial control of hemorrhage and

contamination with packing and temporary

closure, followed by resuscitation in the ICU,

and subsequent re-exploration and

definitive repair once normal physiology has

been restored.

PRINCIPLES

• Control haemorrhage

• Identification of injury

• Prevention contamination

• Avoid further injury

Hypothermia:

• Clinically important if less than 37⁰C for more than 4

h

• Can lead to cardiac arrhythmias, decreased

cardiac output, increassed systemic vascular

resistance

• Can induce and exacerbate coagulopathy by

inhibition of clotting cascade reaction

Acidosis:

• Uncorrected haemorrhagic shock leads into

inadequate cellular perfusion, anaerobic

metabolism and the production of lactatic acid

• Interferes with blood clotting mechanisms and

promotes coagulopathy and blood loss

Coagulopathy:

• Hypothermia, acidosis and the consequences of

massive blood transfusion all lead to the

development of a coagulopathy

• Platelet dysfunction at low temperature

• Activation of the fibrinolytic system

• Haemodilution following massive resuscitation

WHEN TO INSTITUTE

Parameters as a guideline for instituting damage control:• pH less then or equal to 7.2• serum bicarbonate level less than or equal to

15 mEq/L• core temperature less than or equal to 34⁰C• transfusion volume of packed RBCs more than

or equal to 4000 ml• total blood replacement more than or equal to

5000 ml• total fluid replacement more than or equal to

12 000 ml

If all - deathIf one - DCS

PHASES

APPROACH

Before

ER OR DEATH

Now

ER→OR→ICU→OR→ICUER; emergency room, OR; operating room;

STAGE 1 DCS (ABDOMEN)

• initial laparotomy

• identify the main source of bleeding

• perihepatic packing (superior and inferior)

• small gastotomies and enterotomies can be rapidly closed

• resect non-viable bowel and close the ends

• minor pancreatic injuries not involving duct-no treatment

• distal injury including the panceratic duct-distal pancreatectomy

• NO pancreaticoduodenectomy (drainage)

• abdominal closure is rapid and temporary- if there is any doubt about abdominal compartment syndrome, left it open (silo-bag, vacuum-pack technique, towel clip)

STAGE 1 DCS (SKELETAL)

• Stable patient – osteosynthesis

• Polytrauma patient- FE

• Do not insist on anatomical reposition, but on

fracture stabilisation

• Open fracture-debridment

• Control all hemorrhages primarily.

• Avoid early manipulations of long bone fracture.

• Prevents fat embolism.

• Two hit theory.

DAMAGE CONTROL NEUROSURGERY

1. Arrest intracranial hemorrhage.

2. Evacuate the hematoma.

3. Primary closure of dura to prevent

infection.

4. Craniectomy to prevent

compartment syndrome.

STAGE 2 DCS

• Begins in ICU

• The next 24 to 48 hours are crucial

• Correction of metabolic disorder

• Core rewarming

• Correction of coagulopathy

• Complete ventilatory support

• Correction of acidosis

• Identification of occult injury

STAGE 3 DCS – PLANNED REOPERATION

• Window of opportunity is 24-48 hours after the trauma- between the correction of metabolic disorder and the onset of SIRS and MOF

• Removal of the abdominal packs (48-72 h)

• Primary repair with end-to-end anastomosis undertaken

• Copious washout should be performed and the abdomen closed

• The patient sometimes needs early unplanned reoperation-ongoing haemorrhage, abdominal compartment syndrome or peritontis

• Window of opportunity for definitive osteosynthesis is 5-10 days after trauma

INDICATIONS FOR DEFINITIVE SURGERY

1. Core temperature 36°C or above

2. Correction of acid base balance

3. Normalization of coagulation profile.

ADVANTAGES

A. A small study on penetrating abdominal

injuries showed a survival benefit over

historical controls(90% v 58%; P=0.02).

B. Mortality in Iraq war was 10% compared with

24% in Gulf war.

DISADVANTAGES

1. Sepsis and multi organ failure

2. Pneumonia

3. Intra abdominal abscess

4. Enteric fistula

5. Compartment syndrome

REFERENCES

• Brian J. Eastridge et al; Damage control surgery

• Dr. Josip Janković, Dr. Boris Hrečkovski Department of surgery

General hospital Slavonski Brod

• www.slideshare.net