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 • • • • • 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 Acidosis Shock Hypothermia Coagulopathy 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 13 14 11 12 Patients 10 8 6 6 93% 4 2 1 35% 0 Initial Subsequent Stone HH, et al: Ann. Surg. 197:532-5, 1983. Brohi,K et al.: J. Trauma 54:1127-30, 2003. Lived Died Hypothermia 100 100 90 80 79 80 Mortality 60 70 69 70 59 52 50 41 40 40 30 20 10 0 Luna Jurkovich Rutherford 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 <32 C <33 C <34 C <35 C <36 C Phases of Damage Control • Phase I – Resuscitation in the ED • Phase II – Damage Control in the OR • Phase III – Stabilization in the ICU Damage Control in ED – Phase I DON’T SKY DIVE ! The “Old” Face of Trauma Care Before Damage Control Resuscitation The “New” Face of Trauma Care with Damage Control Resuscitation “You don’t have to swell to be well” Charity Hospital Trauma Aphorism Distribution of Trauma patients in NOLA-Blunt (42%), Penetrating (58%) 4.9% of patients had severe injury requiring > 10 U PRBC in 24 hours Hemostatic / Low Volume Resuscitation (LVR) 1.Hybrid permissive hypotension 2.Minimization of crystalloids 3.LVR with: Hextend and hypertonic saline 4.Close PRBC/ FFP / platelets TRAUMA INDUCED COAGULOPATHY Combat Data J TRAUMA 2008 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 • Skin approximation – Towel clips • Bogotá bag • Modified removable prosthesis • Vacuum Assisted Closure (VAC) Bogotá Bag Open Abdomen Advantages Disadvantages • Loss of abdominal domain • Evisceration • Inexpensive • Avoids compartment syndrome • Minimizes heat & fluid loss • Non-adherent • Ease of re-exploration . Vacuum Assisted Closure Vacuum Assisted Closure • • • • 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 • 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). ????? Damage Control in the ICU – Phase III COAGULOPATHY DEATH TRIAD HYPOTHERMIA ACIDOSIS ICU CARE • Ventilatory Management • Secondary Resuscitation • Recognition of Complications – – – – Abdominal compartment syndrome Dehiscence Abscess Fistula 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 Definitive Closure Once the patient has been stabilized and physiologic reserve has been restored, steps should be taken for definitive closure. 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 Biological Materials • Porcine small intestinal submucosa • Human acellular dermis (Alloderm) Advantages • Ideal for contaminated or infected wounds . Disadvantages • Extremely expensive ($25/cm2) • Limited shelf life • 4.5% recurrence rate Component Separation RM RM EO IO TA Ramirez OM, et al: Plast Reconstr Surg 1990;86:519-26. EO IO TA Component Separation RM RM EO IO TA Ramirez OM, et al: Plast Reconstr Surg 1990;86:519-26. EO IO TA Component Separation RM EO IO TA RM EO IO TA 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 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. Conclusions • Damage contol operations can be lifesaving, but they need to be pursued early and performed rapidly • Stabilization in the ICU should focus on resuscitating shock and reversing acidosis, coagulopathy, & hypothermia. Thanks!