DAMAGE CONTROLDr. Sudhanshu Goyal,PGY-1, General Surgery,Civil Hospital Aizawl

Why Damage Control?

"The modern operation is safe for the patient. The modern surgeon must make

the patient safe for the modern operation" - Lord Moynihan

Principles

Lethal Triad: Acidosis, Hypothermia and

Coagulopathy Damage Control Resuscitation (DCR)

Novel resuscitative strategies to limit physiological derangement

Damage Control Surgery (DCS) Treatment strategy of TEMPORIZATION

by prioritizing Physiological Recovery before Anatomical Repair

Four phase strategy DC0: DCR, RSI, early

rewarming and expedient transport to OR

DC1: concurrent DCR and DCS

DC2: ICU resuscitation and stabalization

DC3: Definitive surgery

Indications Massive Blood Transfusion

>10 unit PRBC

Severe Metabolic Acidosis pH< 7.30

Hypothermia <35 degree C

Operative time >90 mins

Coagulopathy Either on lab results or ‘non surgical’

bleeding

Lactate >5 mmol/L

Estimates show 10% of

the major trauma

patients to benefit from

DCS

DC0 Extends from pre-hospital setting to

ER DCR

Deleterious effect of excessive fluid and Acute traumatic coagulopathy

Consist of <C>ABC (RSI) Permissive hypotension Limitation of crystalloid and early transfusion Early use of TXA

Early use of Blood and Blood products Blood components targeting ATC Optimal ratio of PRBS,PC, FFP and other

products

Massive transfusion protocol Prevent delay in accessing blood E.g.

1 pack of un-crossmatched blood in ER f/b protocoled transfusion to prevent clotting

factor depletion

Imaging RSI f/b chest x-ray Spinal precations Pelvic binder If stabilized CT scan Primary and secondary surverys

DC1 (DCS)

Objectives Haemorrhage control Limitation of contaimination Temporary abdominal closure

Preperation OT prepped before taking patient Criciform position Prepped from chin to mid thigh RT, Foley’s Don’t delay for central line

Incision Midline laparotomy In pelvic fracture limit

just below umbilicus Easy to extend

superiorly or laterally

DC1 (DCS) cont…

Haemorrhage control Large clots removed manually Retract and pack each quadrant

sequentially While packing assess degree and

location of significant injuries If still hypotensive – suspect significant

arterial source Occlude aorta sequentially to gain

control

Major vascular injuries Arterial either ligation or

temporary shunt Venous majority can be

ligated, if not shunting Definitive reconstruction

to be avoided

DC1 (DCS) cont…

Haemorrhage control cont… Solid organ injuries

Prolonged repair to be avoided Splenic, Renal and Pancreatic injuries

best by partial or total resection Liver bleeding managed by packing,

tropical hemostatic agents Consider angioembolization whenever

available

Contamination control Control spillage of

intestinal content and urine

Simple bowel perforation in limited number may be repaired, else resection

Reconstruction, stoma creation and feeding tube avaoided

Biliary/ Pancreatic duct injury: controlled fistula

DC1 (DCS) cont…

Abdominal closure Fascial closure not

recommended Temporary closure to

avoid IAH/ACS

Contamination control cont… Biliary/ Pancreatic duct injury: controlled

fistula Bladder injury: Primary suturing with

foleys drainage, if large packing with foley’s drainage

Ureteric injuries: drained over IFT

Abdominal packing: sufficient to provide tamponade but not impeding vascular return or arterial suppy

DC2 Goal:

Reverse hypotension related metabolic failure

Support physiological and biochemical restoration

Normalise lactate within 24 hrs Aggressive Core Rewarming

Improves perfusion and reverses coagulopathy

Correct Coagulopathy FFP, Platelets and Cryoprecipitates

Complete physical examination and relevant imaging

Repair planning Usually require 24 to 36 hrs Unplanned re-operation

Ongoing transfusion despite normal clotting and core temp.

ACS: sustained or repeated IAP >20 mm Hg + new single/multiple organ failure

DC3 Maximum impact on achieving successful

outcome Normothermic, normal coagulation, pH

and lactate (24 – 36 hrs) Operative game plan

Handover (if different surgeon) Irrigate packs to avoid clot disruption Complete re-examination and

definitive repair Additional sites of bleeding controlled,

vascular repairs done and intestinal continuity is restored

Abdominal closure Formal abdominal closure

without tension should be done

If airway pressure >10 cm H2O temporary closure to be done

Can be closed within 1 week

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