Damage control surgery

DAMAGE CONTROL SURGERY DAMAGE CONTROL SURGERY IN ABDOMINAL TRAUMAIN ABDOMINAL TRAUMA

Zeka

CONTENTSCONTENTS

- The principles in Damage Control surgery- When to decided from standard surgical approach to

damage control surgery- Preparation of the patient- Approach of organ injuries- Complications- Re- laparatomy- Case- Referrences

DAMAGE CONTROL SURGERYDAMAGE CONTROL SURGERY

MULTIPLE TRAUMA PATIENTS ARE MORE LIKELY TO DIE FROM THEIR INTRAOPERATIVE METABOLIC FAILURE THAT FROM A FAILURE TO COMPLETE OPERATIVE REPAIRS


MULTIPLE TRAUMA PATIENTS DIE FROM A TRIAD:

COAGULOPATHY

METABOLIC ACIDOSIS

HYPOTHERMIA


STANDARD SURGICAL APPROACH

DAMAGE CONTROL APPROACH

It is better to cure in more phases than to kill in one …


PRINCIPLES

1. CONTROL OF HAEMORRHAGE

2. PREVENTION OF CONTAMINATION

3. PROTECTION FROM FURTHER INJURY


HYPOTHERMIA

Trauma patients are hypothermic due to enviromental conditions at the scene.Inadequate protection, IV fluid administration, and blood loss worse hypothermia.Shock leads to decreased cellular perfusion and inadequate heat production.Hypothermia has multiple effects on the bodyfuncions and exacerbates coagulopathy.


ACIDOSIS

Shock leads to decreased cellular perfusion, anaerobic metabolism and the production of lactic acid.This leads to profund metabolic acidosis which promotes coagulopathy.


COAGULOPATHY

-Hypothermia, metabolic acidosis and massive

blood transfusion lead to coagulopathy.-Coagulopathy worsen haemorrhagic shock

and in turn it worsens hypothermia and acidosis, prolonging the vicious circle.

WHEN TO DO DAMAGE WHEN TO DO DAMAGE CONTROL SURGERYCONTROL SURGERY

STANDARD SURGICAL APPROACH

DAMAGE CONTROL APPROACH

- pH below 7.2- Core temperature below 32/ 34 C- More than 5 transfusion

?

Do not wait !!


PREPARATION

These patients should be transferred rapidly to the OR.All investigations that will not immediately affectpatient management should be deferred.These patients require operative control of haemorrhage and simultaneous vigorous resuscitation with blood and clotting factors. All fluids should be warmed and the patient covered and actively warmed as possible.


LAPAROTOMY

The incision should be made from the xiphoid to the pubis. Opening the abdomen may result in dramatic haemorrhage and hypotension, control is initially achieved with multiple abdominal packs. If there is continued haemorrhage with packs in place, aortic control may be necessary.


LAPAROTOMY

Aortic control is generally achieved at the diaphragmatic hiatus with blunt finger dissection and finger pressure by an assistant followed by aortic clamping.


LAPAROTOMY

.The next step is to identify the source of bleeding..Examination of the abdomen must be complete..Immediate control of haemorrhage is with direct blunt pressure using the surgeon hands or abdominal packs..Vessels which can not be ligated without loss of life/limb are treated with indwelling shunts

DAMAGE CONTROL SURGERYDAMAGE CONTROL SURGERYLAPAROTOMY

LIVER, 1

The basic technique for control of hepatic hemorrhage is peri-hepatic packing.


LIVER, 2

The liver parenchyma can be compressed manually initially, followed by ordered packing in the anteroposterior plane.Even retrohepatic venous and IVC injuries may be controlled in this manner.The patient with hepatic packing should be considered for transfer to the angiography suite ( if applicable) immediately after operation to identify and control with embolization any arterial haemorrhage.


SPLEEN

Splenectomy is the treatment of choice for spleen injuries in this setting.

Attempts at splenic conservation are too time-consuming and prone to failure.


RETROPERITONEUM

Non-expanding, stable retroperitoneal and pelvic hematomas should not be explored and may be treated with abdominal packing. Subsequent angiographic embolization may be required.Only expanding hematomas require evacuation and exploration for serious vascular injury.


LAPAROTOMYGASTROINTESTINAL TRACT, 1

Once control of haemorrhage has been obtained, prevention of contamination is achieved by the rapidly closure of hollow viscus injury. This may be definitive if there are only small enterotomies requiring primary suture. With extensive damage to the bowel it is wiser to resect non-viable bowel and close ends, leaving them in the abdomen for anastomosis at the second procedure.


LAPAROTOMYGASTROINTESTINAL TRACT, 2

Ileostomies or colostomies should preferably not be performed in a damage control setting, especially if the abdomen is to be left open, as control of contamination is almost impossible.


PANCREAS

Minor pancreatic injuries require no treatment.In case of massive injuries, the pancreas should be debrided only, because patients will not survive complex operation such as pancreaticoduodenectomy.


ABDOMINAL CLOSURE

Abdominal closure is rapid and temporary. The abdomen should be left open as a laparostomy with a bag or vacuum-pack technique to avoid abdominal compartment syndrome.


ABDOMINAL CLOSURE

COMPLICATIONS OF COMPLICATIONS OF Damage control SurgeryDamage control Surgery

Failure to recognize non-coagulopathic hemorrhage which leads to exsanguination

Abdominal compartmental syndrome which leads to multi organ failure

Formation of enteric fistulas esp in pts with M.O.F and open abdomens for a long time

ARDS, intraabdominal abcesses, sepsisMortality at 60%


CRITICAL CARE

The priority of the critical care phase of treatment is rapid reversal of metabolic failure. The patient must be actively warmed, coagulopathy and acidosis must be corrected.

The next 24-48 hours are crucial if the patient requires a second surgical procedure.


REOPERATION

Timing of reoperation is crucial. There is a window of opportunity between correction of metabolic failure and the onset of a multiple organ failure.This window occurs at 24-48 hours after the first procedure


REOPERATION

The principles of reoperation are:

• removal of packs• complete inspection of the abdomen• haemostasis• restoration of intestinal integrity• abdominal closure


REOPERATION

Packs, especially around the liver or spleen, should be removed cautiously as removal may lead to further bleeding. Soaking the swabs may aid this process.Any intestinal repair should be inspected and repair with anastomosis undertaken.Copious washout should be performed and the abdomen closed with standard technique.

CASECASE

B.M, D.O.A 28/10/13Hx : hit by a lorry on the left side of

abdomen, no L.O.CExam: RR 22, PR 101, Bp 80/50, GCS

15/15, Hb 10, WBC 17.8FAST: liver trauma

Mx: Hrly vitals signs, repeat FBC 4 hrly30/10/13: RR 22, Bp 123/65, PR 91, Hb 7.7

and signs of peritoneal irritation31/10/13: laparatomy, 4000cc of blood

harvested, packing of liver injury4/11/13: re- lap, repair of liver injury,

sphincteroplasty5/11/13: multi organ failure6/11/13 : Died

referencesreferences Physiologic rationale for abbreviated laparotomy. Surg Clin North

Am. (1997);77:779–782. [PubMed] ‘Damage control’: An approach for improved survival in

exsanguinating penetrating abdominal injury. J Trauma. (1993);35:375–383. [PubMed]

The abdominal compartment syndrome. Surg Clin North Am. (1996);76:833–842. [PubMed]

Delayed gastrointestinal reconstruction following massive abdominal trauma. J Trauma. (1993);34:233. [PubMed]

Planned reoperation for trauma: A two year experience with 124 consecutive patients. J Trauma. (1994);37:365. [PubMed]

Damage control surgery

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