Damage Control Symposium – 24th November 2014

The Cambridge Damage Control Symposium was held in the Mohammed Bin Rashid Academic Medical

Center in Dubai Healthcare City on the 24th November 2014. I was kindly sent by National Ambulance

LLC as a member of their Clinical Education Team, and they have allowed me to produce this report for

both staff of National Ambulance and for the FOAM community.

Damage control resuscitation is a term used to encompass the range of strategies focused on balancing

haemostatic resuscitation, permissive hypotension, lung protection, wound protection and neuro-

protection whilst maintaining tempo and critical organ and system support.

In this symposium, experienced members of pre-hospital and emergency department trauma teams

looked at current damage control resuscitation strategies and discussed the practical considerations in

implementing them.

The day started with Dr. Rod McKenzie, Consultant in Emergency Medicine and director of the Major

Trauma Centre at Addenbrooke Hospital, and prehospital physician with London Air Ambulance.

Components of Damage Control Resuscitation

A – Airway Management The day followed the ATLS standard A-B-C-D-E approach to Damage Control Resuscitation. First up was

Airway. Some of the key points from this talk were:

Decisions for prehospital anaesthesia are not based on GCS criteria! Candidates for perhospital

anaesthesia and airway control are:

1. Failure to maintain the airway

2. Failure to protect

3. Failure to oxygenate

4. Failure to ventilate

5. Expected clinical course

Always weigh up the risk of anaesthesia versus the risk of none.

Primary Survey (A-B-C-D-E) & Life Support

C- Permissive hypotension

C - Haemostatic resuscitation

C - Wound protection

A & B - Lung protection

D - Neuro protection

Is it an airway problem v breathing problem?

• Near death (agonal respirations/cardiac arrest/anticipated laryngoscopy) = crash intubation

• Not near death = Assess for difficult DL or BVM. If difficult then reconsider risk/benefit

There is no such thing as a failed intubation...it is failed laryngoscopy.

BVM is important for rescue of airway!

Plan A - RSI > DL > Bougie/ET

Plan B - rescue ventilation

Plan C - rescue oxygenation

Plan D – Surgical

Ref Difficult Airway Society (http://www.das.uk.com/files/rsi-Jul04-A4.pdf)

Crash intubation = facemask, BVM to provide oxygenation. Equipment dump if possible.

Failed plan A or B = go to plans C/D

Sux useful if near-death and patient has increased muscle tone/trismus.

Consider primary surgical airway in difficult airway prediction (max-fax injuries, access difficult)

RSI

1. Preparation

2. Preoxygenation

3. Pretreatment

4. Paralysis with induction

5. Positioning

6. Placement with proof

7. Postintubation management

Is the patient LEMON positive?

Don’t forget adequate preoxygenation! Desaturation occurs faster in different patient populations.

Time to Desaturation for Various Patient Circumstances. Source: From Benumof J, Dagg R, Benumof R. Critical hemoglobin desaturation will

occur before return to an unparalyzed state following 1 mg/kg intravenous succinylcholine. Anesthesiology 1997;87:979.

Optimise the airway!

Complete checklist – “to err is human”

Then proceed.

Can use ketamine for induction (2mg/kg normal; 1mg/kg in frail,shocked,elderly)

NB – sux is based on actual body weight

Don't keep it to yourself, verbalise what you can see under DL

Cannot understate capnography!!

Movement is high risk - increasingly indefensible to not have capnography, even on SGAs

If 1st attempt failed, don't just do the same again!

B - Ventilatory Support & Lung Protection ATLS Deadly Dozen!

Prevent Lung Injury

Reduced Expansion

Atelectasis

Pain & narcotics

Aspiration

SIRS

Emboli

Increased work of breathing

Pulmonary haemorrhage

Excess fluid administration

Structural damage

What is lung protection?

Optimise O2 delivery

Treat

Minimise further injury

Ventilation - alveolar mechanics videos

Normal: http://www.youtube.com/watch?v=Om8wkwWInPM

Low TV: http://www.youtube.com/watch?v=eK19izkSQZo

High TV: http://www.youtube.com/watch?v=M9uI9xKWW-E

Injured lungs = baby lungs. Any ventilation is harmful

Decrease volume, increase rate, increase FiO2, +/-PEEP

e.g. 6ml/kg; 12bpm; 0.6-1.0 FiO2; PEEP 5

Have a low threshold for open thoracostomy.

Intubated, PPV, thoracic injury = open thoracostomy.

Classic ATLS signs of tension pneumothorax are uncommon!

Differentiate spontaneous respiration v ventilated pneumothorax

We miss flail segments…around the back!

Humidification and other ARDS approaches can reduce lung injury

C - Circulatory Support We’re relearning the lessons of war.

Haemostatic resuscitation – preserve blood, not replace it!

1. Stop compressible bleeding

2. Reduce non-compressible bleeding

3. Prevent coagulopathy

4. Administer TXA

5. Consider risk/benefit of transfusion

6. If transfusing then balanced RBC:FFP:Plat on a 1:1:1 ratio

Don't forget the bleeding basics!

• Direct pressure!

• Gauze

• Pressure dressing

• TQ

• Haemostatic agent

Basic equipment, aggressive search for bleeding & show no mercy to blood loss!

Celox - pack the wound

Most bleeding patients are already coagulopathic or are at high risk of coagulopathy

Hypothermia, blood loss etc - stop!

Assume coagulopathy - manage before labs

Give no fluids that do not clot or carry oxygen!

Permissive Hypotension Small subset of patients – may be useful. MTP activated, keep shocked until OR. Penetrating trauma

mostly. If conscious on arrival – always watching perfusion (mentation)

Goals are not always achievable. No literature on permissive hypotension in blunt trauma.

Tube thoracostomy if bleeding - insert drain; we should be auto-transfusing this blood back in!

TXA

CRASH2: 274 hospitals, 40 countries, 20000+ pts.

• <RIP if given <3hrs

• 32% reduction in RIP

Blood - pre-alert or use if you have! MTP needs prealert!

D - Neuroprotection Single hypotensive or hypoxic episode = 2 x RIP

Goal is the prevention of 2nd degree brain injury

Maintain CPP!

4 Hs of secondary injury

Hypoxia

Hypotension

Hyper/hypocarbia

Hypothermia

Goals

1. SpO2 ~ 92%.

2. MAP > 80 mmHg (to maintain CPP/CBF)

3. Low N Co2 4-4.5kPa/35-45mmHg. Watch the ETCO2. Mortality >if ETCO2 outside N. If unequal

pupils, hyperventilate to ETCO2 of 3kPa

4. Maintain temp 35-37C

5. Ideally 4 hrs from injury to surgery - actually ASAP!