PowerPoint - Phoenix Surgical Society

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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
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!
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