Surgery

Prof. Marius Keel, MD, FACS

General and Trauma Surgeon

Consultant for Pelvic and Spinal Surgery

Department of Orthopaedic Surgery

Bern, Switzerland

Damage Control

SurgeryDamage Control

SurgeryWarum, Wann und Wie ?

Damage Control - Schadensbegrenzung

Warum, Wann und Wie ?

58

Management und operative Akutversorgung des Polytraumas

Pathophysiology

Damage Control

Polytrauma

> Severity of injuries (ISS ≥17 pts.)

> Physiological status

Hypothermia

Acidosis

Coagulopathy

Lethal Triad

> Host defense

Keel et al. n=1191, 1.96-9.04; ISS≥17pts.

76%

25%

60%

32%

23%

58%

> Injury pattern

„Killers“ in Polytrauma

> Head injury (66%)

Keel et al. n=1191, 1.96-9.04; ISS≥17pts.

Coagulopathy- Dilution

- Consumption

Massive

transfusion

≥ 10 U PRBCs in

first 24 hrs

Ongoing bleeding

> Sepsis, MOF (13%)

> Hemorrhagic shock (21%)

35.5Hypothermia°celsius

Acidosis lactate mmol/l

Coagulopathy prothrombin time %

2.8

83

35.3

3.5

74

34.2

6.3

57

Lethal Triad

Mortality (36%): 28% 33% 67%

Hemorrhagic Shock and Mortality

I<750ml

-

-

n = 630

53%

II750-1500ml

>100/min.

-

n = 368

31%

III/IV>1500/2000ml

>120/min.

<90mmHg syst.

n = 193

16%

Keel et al. n=1191, 1.96-9.04; ISS≥17pts.

Primary survey

X-ray (thorax, pelvis)

FAST

Multislice CT ?

Resuscitation:

Preservation of

perfusion and

oxygenation

Vital functions?

Response?Life saving

surgery_

„in extremis“

Keel M, Labler L, Trentz O.

Eur J Trauma 2005; 31:212

1. Surgical approach to airway for imminent asphyxia

3. Surgical control of hemorrhage

Pleural cavity

Peritoneal cavity

Pelvic fracture

Central amputation

Components of Life Saving Surgery

2. Decompression of cavities

Tension pneumothorax

Cardiac tamponade

Acute EDH

Keel, Labler, Trentz. Eur J Trauma Emerg Surg 2005; 31:212

-1030

-140/20 mmHg

-140 /min.

-Lactate 13 mmol/L

-Hb 10 g/dL

-1000 work accident

-Scoop and run

-OP 1040-1150

-120/15 mmHg

-140 /min.

-Cardiac arrest –

open cardiac massage

-Aortic clamping

Emergency Department Thoracotomy

Soreide et al. Scand J Surg 2007;96:4-10

Cothren et Moore. World J Emerg Surg 2006

blunt penetrating Total

EDT 37(32.5%) 8(7.0%) 45 (39.5%)

ET (OR, ICU) 41(35.9%) 28(24.6%) 69 (60.5%)

78 (68.4%) 36 (31.6%) 114

Gun shot/Stab - 12 (33.3%)/24 (66.6%) -

Age 39.6 41.5 40.2

Male : Female 76% : 24% 78% : 22% 76% : 24%

Mortality EDT/ET 94.6% / 61% 25% / 11% 82% / 41%

8

12

3

12

5

7

9

17

1415

12

0

2

4

6

8

10

12

14

16

18

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

EDT+ET in 11 y

Division of Trauma Surgery

University Hospital Zürich

Switzerland

Labler, Trentz, Keel

[n]

114 Resuscitative Thoracotomy in 11y

Outcome after Emergency Department Thoracotomy (EDT)

Soreide et al. Scand J Surg 2007;96:4-10

Case - Basic Imaging

Case - C-Clamp and Angiography

22:30Day 0 - 21:40

Day 1 - 00:26

Case - Pan-CT-Scan

> Intraperitoneal

hematoma

> Retroperitoneal

hematoma

> Scrotal

hematoma

Case - Retrograde Uretrocystography and Scrotal Decompression

Day 1 - 10:25

? > Involvement of urologists

Case - Explorative Laparotomy

Day 3

4 quadrant peritonitis

Mesenteric injuries of small bowel (necrosis,

perforations) and sigma

Intra- and extraperitoneal bladder rupture

Case - SigmoidostomyExtraperitoneal Approaches for Pelvic Stabilization

> Initial ongoing bleeding after angiography

> Missed intraabdominal lesions (small

bowel, sigma, bladder)

> Unnecessary scrotal decompression

> Abdominal sepsis

> Open abdomen with abdominal wall hernia

> Deep veneous thrombosis

Priorities of Acute Treatment

1. Shock treatment

2. Control of hemorrhage

3. Treatment of coagulopathy

Hypothermia

Acidosis

Coagulopathy

Lethal Triad

4. Prevention of septic

complications

5. Organ-/limb saving

Multiple Organ Failure after Life Saving Surgery

Posttraumatic CHAOS

> Cardiovascular shock

> Homeostasis

> Apoptosis

> Organ dysfunctions

> Immune Suppression

Bone. Crit Care Med 1996; 24:1125

Pathophysiological Cascade

Endothelial/Parenchymal Cellular Damage

MODS/MOV

Neuroendocrine Reaction

Pain, Fear, Stress

Complement System Leucocytes-Endothelial-Interaction

PMN -„Respiratory

burst“

Coagulation Cascade

Acute Phase Reaction

Metabolic Disorder Kallikrein-Kinin-System

SIRS

AgTLymphocyte

Antigen Presentation

Antigen ToxinsTissue

Damage

Macrophage

TNF-a, IL-1b, IL-6, IL-8, IL-12, IL-18, MMF, HMG-1,

G-CSF, GM-CSF, PGE2, LTB4, TXA2, PAF

TH1: IL-2, IFN-g, TNF-b

Fractures BacteriaHypoxia/Hypotension

Keel, Trentz. Injury 2005; 36:691

CARS

Immuno-suppression

Infection

TH2: IL-4, IL-10, IL-13, TGF-b

Organ/Soft Tissue Injuries

Hemorrhagic Shock and Morbidity

100

80

60

40

20

0

% infe

cte

d/n

on-infe

cte

d p

atie

nts

infected noninfected

Hemorrhagic shock class

I II III IV

% p

atie

nts

with

SIR

S / s

ep

sis

100

80

60

40

20

0

no SIRSSIRS 3/4sepsis SIRS 2

I II III IVHemorrhagic shock class

> Inclusion: ISS ≥17 pts., survival >72 hrs

> N=972 (age: 40.2 y; ISS: 31.9 pts.; late mortality: 10.5%; blunt trauma: 91.4%)

> Hemorrhagic shock: I (n=582) – II (n=309) – III (n=56) – IV (n=25)

Lustenberger et al. Eur J Trauma Emerg Surg 2009

27

Multiple Organ Dysfunction

Syndrome (MODS)

Host Defense Response

- reversible -

„Two Hit“ – Model Keel, Trentz. Injury 2005;36:691

Moore et al. J Trauma 1996;40:501

First Hits

-Hypoxia

-Hypotension

-Organ injuries

-Soft tissue injuries

-Fractures

Systemic Inflammatory

Response Syndrome (SIRS)

-Temperature

-Pulse

-Breathing

-Leukocytes

Crit Care Med

1992;20:864

Multiple Organ Failure (MOF)

Host Defense Failure Disease - irreversible -+Bacteria

Sepsis

Second Hits

Endogen (antigenic): - Hypoxia

- Hypotension, Azidosis

- Ischemia/Reperfusion

- Cellular detritus

- Contamination/Infection

Exogen (interventional): - Surgery with blood loss,

Tissue damage, Hypothermia

- Neglected Trauma

- Missed Injuries

- Massive transfusions

Damage Control Concept

Stop the bleeding –

Life Saving Surgery

Damage Control Surgery (DCO)

> Surgical control of hemorrhage

> Angiographic control of hemorrhage (Transcatheter arterial embolisation (TAE))

> Massive transfusion protocols (MTPs)

> Correction of coagulopathy

> Correction of hypothermia

Mitigate the lethal triad –

Damage Control Resuscitation

Damage Control – History – US Navy

> …keeping afloat a badly damaged ship by procedures tolimit flooding, stabilize the vessel, isolate fires andexplosions and avoid their spreading…

History: DC – DCO

> Pringle-maneuver Pringle. Ann Surg. 1908; 48:541

> Intra-abdominal packing Feliciano, et al. J Trauma. 1981; 21:285

> Damage Control as approach Rotondo, et al. J Trauma. 1993; 35:375

> Early packing – outcome Garrison, et al. J Trauma. 1996; 40:923

> Timing of fracture treatment – DCO (Damage Control Orthopaedic Surgery) Pape, et al. Am J Surg. 2002; 183:622

Trauma – Care

Primary survey

X-ray (thorax, pelvis)

FAST

Multislice CT ?

Resuscitation:

Preservation of

perfusion and

oxygenation

Vital functions?

Response?

Early total

care+

Intensive

care unit

Day-1-

surgery

_„borderline“

Keel, Labler, Trentz.

Eur J Trauma 2005; 31:212

Physiologic

balance?

Scoring?

Ressources?

Secondary survey

X-ray (extremities)

Multislice CT

+

„responder“

?„transient

responder“

Damage control:

• Preemptive intervention

Life saving

surgery

_„in extremis“

Damage control:

• Preemptive intervention

• „Bail-out“ procedure

Case - Damage Control Surgery

-OP-time: 2:45

-Lactate: 2,1 mmol/L (initial: 3.2)

-Voluven 2200 mL; RL 8000 mL

-No RBC, FFP, Tc

Suicide jump 5th floor

-1135

-105/60

mmHg

-145/min

-Lac 5.7

mmol/l

-Hb 8.2

1030

Priorities ?

Techniques?

Day 0

-OP time 5:45 hrs

-7 RBC

-cellsaver 680 ml

-8 FFP

-11.2 l ringer lactate

48 hrs

1. Bleeding Control

“Open chimney”

Abbdominal/liver packing

Pringle maneuver

External fixation and

pelvic packing

or embolization

Repair

Vascular

exclusionResection

Source of Abdominal Bleeding

> Retroperitoneal bleeding (pelvis)

• Prevesical venous plexus

• Presacral venous plexus

• Fracture

• Small arteries: obturator/pudendal/gluteal

• Large–bore vessels

> Intraperitoneal bleeding (pelvis)• Positive FAST in 39% - 97% intraperitoneal lesion

• Solid organ lesions (liver 10%, spleen 6%) Ruchholtz, et al. J

Trauma 2004;57:278

Demetriades, et al. J Am Col Surg 2002;195:1

Grotz, et al. Injury 2006;37:642

Kataoka, et al. J Trauma 2005;58:704

> Multislice CT

> Retrograde

cystography

(intraop or preop)

> Explorative

laparotomy

2a. Reduction of Contamination (Diagnostics)

2a. Reduction of Contamination (Treatment)

> Treatment of hollow organ injuries:

Intraperitoneal lesions and unstable pelvic fracture: 31%

Demetriades et al. JACS 2002;195:1

2a. Reduction of Contamination (Treatment)

2b. Reduction of Contamination

> Débridement of open fractures

3. Decompression of Compartment Syndrome

> Imminent

> Manifest

4. Resection of Avital Tissue

Labler et al. Eur J Trauma Emerg Surg 2008

> Débridement of Morel Lavallé lesion

5. Fixation of Skeletal Instabilities

> Temporary fixation: External or internal fixators (LCP ?)

> Definitive fixation: Plate, Screws

> Reduction of trauma load

Risk Factors for Early Mortality after Damage Control Surgery

Variable Odds Ratio (95% CI) p Value

INR >1.2 10.64 (1.32 - 83.33) 0.026

Base Deficit >3 mmol/L 4.85 (1.10 - 23.81) 0.040

AIS Head ≥3 4.27 (1.55 - 11.76) 0.005

Body Temperature <35°C 3.68 (1.15 - 11.76) 0.029

Lactate >6 mmol/L 2.96 (1.00 - 9.09) 0.050

Hemoglobin <7 g/dL 2.76 (1.02 - 7.46) 0.045

Frischknecht et al. 2010 (submitted)

> DC procedures in 319 pat. (age: 39.3 y; ISS: 36.6 pts.; SBP <90

mm Hg: 8.7%)

> External fixator: C-clamp (10%), external fixator pelvis (2.5%),

external fixator extremities (60.5%)

> Packing: chest (4.7%), intraabdominal 25.7%), retroperitoneal (6.9%)

> Early mortality: 52/319 (16.3%)

> Late mortality: 22/267 (8.2%)

All patients

(n=50)

Early survivors

(n=34)

Non-survivors

(n=16)p-value

Hemoglobin (g/dL) at

admission, mean ± SD7.4 ± 3.1 8.6 ± 2.9 4.9 ± 2.0 <0.001

Hematocrit (%) at

admission22.2 ± 9.1 25.6 ± 8.4 15.0 ± 6.0 <0.001

Prothrombin time (%) 55.5 ± 26.6 66.5 ± 23.4 34.1 ± 18.5 <0.001

SBP (mm Hg) at admission 109.5 ± 29.8 117.3 ± 25.2 90.4 ± 32.1 0.002

HR at admission 104.2 ± 21.0 100.2 ± 17.5 110.4 ± 27.7 0.02

Crystalloid solution

administration from injury

until 1 h after admission (L)

2.9 ± 1.9 2.7 ± 1.5 3.4 ± 2.4 0.42

Colloid solution

administration from injury

until 1 h after admission (L)

2.6 ± 1.8 2.1 ± 1.5 3.7 ± 1.8 0.001

PRBC administration within

1 h after admission (Units)4.7 ± 5.4 2.6 ± 3.9 8.5 ± 5.9 <0.001

FFP administration within 1

h after admission (Units)1.1 ± 1.9 0.8 ± 1.6 1.6 ± 2.3 0.20

All patients

(n=50)

Early survivors

(n=34)

Non-survivors

(n=16)p-value

Type B 16.0% (8) 8.8% (3) 31.3% (5) 0.09

B1 12.0% (6) 2.9% (1) 31.1% (5) 0.01

B2 4.0% (2) 5.9% (2) 0% (0) 1.00

Type C 84.0% (42) 91.2% (31) 68.8% (11) 0.09

C1 44.0% (22) 47.1% (16) 37.5% (6) 0.56

C2 4.0% (2) 2.9% (1) 6.3% (1) 0.54

C3 36.0% (18) 41.2% (14) 25.0% (4) 0.35

Eur J Trauma Emerg Surg 2009

Characteristics

Early

Survivors

(n=34)

Non-

Survivors

(n=16)

All

(n=50)

Laparotomy 26 (77%) 14 (88%)34

(77%)

Cross-clamping

Aorta2 (6%) 8 (50%)

10

(20%)

Pelvic packing 23 (68%) 12 (75%)35

(70%)

Thoracotomy 0 7 (44%) 7 (14%)

Mortality4 (12%):

MOF 3,

head injury 1

16: hemorrhage

13, head injury

3

20

(40%)

Time to C-clamp (min)

39.5 ± 2.2

Days till definitive pelvic stabilization

3.5 ±0.5

Age: 45 y

m:w=26:24

ISS: 42 pts.

12 years

Shock - Monitoring

AUC 95% CI p-value

BE at admission 0.856 0.751 – 0.961 <0.001

BE 1 h after admission 0.915 0.836 – 0.993 <0.001

Lactate at admission 0.784 0.651 – 0.917 0.001

Lactate 1 h after admission 0.825 0.705 – 0.944 <0.001

pH at admission 0.804 0.671 – 0.938 <0.001

pH 1 h after admission 0.905 0.819 – 0.992 <0.001

Shock - Monitoring

Abt et al. Eur J Trauma Emerg Surg 2009

Damage Control Resuscitation (DCR)

> Permissive hypotension (Cave head injury)

> Minimizing crystalloid-based resuscitation strategies

> Massive transfusion protocols (MTPs): predifined blood products

- PRBCs

- FFP

- platelets

> Adjuncts to massive transfusion:

- Pharmacological adjuncts:

- fibrinogen

- rfVIIa,…

- Auto-transfusion/cell saverNunez et Cotton. Curr Opin Crit Care 2009;15:536-41

Need For Massive Transfusion

> ED systolic blood pressure <90 mmHg (0=no, 1=yes)

> ED heart rate 120 (0=no, 1=yes)

> Penetrating mechanism (0=no, 1=yes)

> Positive fluid on abdominal ultrasound (0=no, 1=yes)

Assessment of Blood Consumption (ABC) score

Score of 2 predicts 38% need for MT

Score of 3 predicts 45% need for MT

Score of 4 predicts 100% need for MT

Nunez et al. J Trauma 2009;66:346-52

Duchesne et al. J Trauma 2008;65:272-8

Plasma Transfusion (FFP) versus RBC

4 year

retrospective

study, New

Orleans

p=0.06

fibrinTAFIa

TAFI

Damage Control of Coagulopathy

pre-kallikrein

FXIIa

FXIFXIa

FIXa

FXII

kallikrein

FXa

FIX

FX

FVIIFVIIIa FVIII

FVFVa

prothrombin (FII)

fibrinogen (FI)

FXIIIa

FXIII

ATIII

ATIII

ATIIIATIII

ATIII

C1-inhibitora1PI

C1-inhibitora1PI

TFPI

protein C-protein S

bradykinin

kininogen

plasminplasminogen

classical pathway

alternative pathway

membrane attack complex (MAC)

C5b,6,7,8,9

C1s

C1 (C1q,C1r,C1s)

C1-inhibitor

C3

u-PA and t-PA a2AP a2MGPAI-1

anaphylatoxinsC3a,C4a,C5a

disseminated intravascular coagulation (DIC)

C5-convertase

opsoninsC3b,C4b

C5

fibrinolytic products

vascular permeability

endothelial + parenchymal cell damages

proinflammatory cytokines, toxins

antigen-antibody-complexes complement cascade

chemotaxis respiratory burst

coagulation system

contact activation

C3-convertase

Keel, Trentz. Injury 2005;36:691

initiationsubendothelial cells

FVIIaTF

amplificationplatelets

propagation

„thrombin burst“ on activated platelets

thrombin (FIIa)

fibrin clots

Monitoring of Traumatic Coagulopathy

> Plasma-based routine coagulation tests (RCoT):

- Prothrombin time (PT)

- Activated partial thromboplastin time (APTT)

Reflect only small amount of thrombin formed during initiation of coagulation!

> Viscoelastic haemostatic assays (VHA):

- Thromboelastography (TEG®)

- Rotation Thromboelastometry (ROTEM®)

Cell-based model of haemostasis emphasizing importance of tissue factor (TF) as initiator of coagulation and pivotal role of platelets!

Coagulopathy – Diagnostics

Viscoelastic Haemostatic Assays

Johansson et al. Scand J Trauma Resusc Emerg Med 2009

> Initiation phase:

- reaction time (R)

- clotting time (CT)

> Amplification phase:

- Clot formation time

(K/CFT)

> Propagation phase

(„thrombin burst“):

- alpha angle

- clot strength

- clot stability

Johansson et al. Scand J Trauma Resusc Emerg Med 2009

Coagulopathy – Diagnostics

Viscoelastic Haemostatic Assays

Hyperfibrinolysis and Hypofibrinogenaemia

Brenni et al. Acta Anaesthsiol Scand 2009

Fig. 2

Fig. 3

Fig. 4

-140/20 mmHg

-140 /min.

-Lactate 13 mmol/L

-Hb 10 g/dL

-1g tranexamic acid

-7 PRBC

-16g fibrinogen

-3500 ml colloids

-5500 ml crystalloids

3 hours:

rFVIIa (Novoseven®)

> Trial phase 2 (143 blunt trauma and

134 penetrating trauma, rFVIIa): In blunt

trauma significant reduction of RBC

after rFVIIa (trend in penetrating

injuries); no influence on mortality

Boffard et al. J Trauma 2005;59:8-15

CONTROLTM-„Clinical Trial on the Effect of rFVIIa

on Traumatic Blood Loss“: F7Trauma-1711-Study –multi-

center, randomized, double-blind, parallel group, placebo

controlled trial to evaluate the efficacy and safety of activated

recombinant factor VII (rFVIIa/NovoSeven®/ NiaStase®) in

severely injured trauma patients with bleeding refractory to

standard treatment. Trial Phase 3Global CONTROL Results Meeting

December 2008, Madrid

> Trial phase 3:

- 481 blunt trauma and 92 penetrating

trauma (576 randomized), rFVIIa (200

mcg/kg-1+3h 100mcg/kg)

- in blunt and penetrating trauma

significant reduction of RBC and

FFP after rFVIIa (1.3 U RBC and 2.7

U FFP)

- no influence on mortality or morbidity

Ongoing Bleeding in CONTROLTM-Study: 22 patients in 28 months (between 2005 and 2008) No 2 worldwideKeel et al. Division of Trauma Surgery, University Hospital Zurich

Case 14

9 pelvic fractures/ 22patients (41%)

† Head

injury† MOF

> Stage 4: Second Look„s and Schedulded Definitive Surgery

> Stage 5: Secondary Reconstructive Surgery

Damage Control Stages

> Stage 1: Indications

> Stage 2: Damage Control Surgery

> Stage 3: Resuscitation in ICU

Experience

Tactics

Dynamic

FlexibilityWindow of Opportunity

Days 4-10

Take Home Message: Prevent Death !

> Life Saving Surgery:

– Operative control of airway

– Decompression of cavities

– Surgical control of hemorrhage

– Team

– Tactic

- Time>Fast decision

making for Life

Saving Surgery

and/or DCS/DCO

– Bleeding control

– Reduction of contamination

– Decompression of compartment syndrome

– Resection of avital tissue

– Fixation of skeletal instabilities

> Damage Control Concept