Damage Control Flashcards
What is the Principle of Damage Control ?
1-Control Hemorrhage
2-Limit Contamination
3-Maintain Adequate Perfusion
Damage Control Interventions
1-Laparotomy
2-Thoracotomy
3-Vascular Surgery
Indications for Damage Control Surgery
Bleeding
Hypoperfusion
Acidosis
Hypothermia
Coagulopathy
Damage Control Laparotomy
-large midline incision
-Packs should be placed in all four quadrants
-Removal of packs can either be in order of least likely area of hemorrhage to most, or vice versa
-Be systematic, so injuries are not missed
-Hemorrhage should be controlled
-Approaches to controlling hemorrhage varies on location and organ involved
DCO Liver
-For easily recognizable injuries > direct suture ligation
#1 chromic on a large needle (“ liver stitch”) for exposed liver or large lacerations
4-0 Prolene suture for control of bleeding vessels or parenchyma.
-Cautery or Argon > controlling any raw surface injuries.
Injuries by small projectile > compression device constructed from a Penrose drain and red rubber
DCO Liver , Source Not Identified
-Pringle maneuver
-Bleeding despite a Pringle maneuver indicate a retrohepatic inferior vena cava injury for which suture repair or packing should be pursued.
Nonexpanding hematomas in the retroperitoneum should be left alone as opening them may lead to uncontrolled bleeding
DCO Spleen
major hemorrhage, or hemodynamic instability, a splenectomy should be performed.
DCO Kidney
-Nonpulsatile, nonexpanding hematomas in zone 2 involving the kidneys should be left alone.
-Active, pulsatile, or expanding hematomas likely will require nephrectomy.
-Before opening Gerota’s fascia in pursuit of a nephrectomy, the contralateral kidney should be identified and examined to ensure that it is normal in size and not injured.
DCO Pancreas
1-Control bleeding > often managed with direct suture ligation.
2-Establish appropriate drainage > to control any pancreatic leak
3-trauma to the head of the pancreas may require a pancreaticoduodenectomy
Reconstruction should not be undertaken in the index case but should be done at take back
DCO Viscera ( Injuries to hollow viscous organs e.g., stomach, small intestine, large intestine )
1-Aim to prevent contamination
2-Direct 2 Layers Repair If injury is small
3-Segmental Resection if Extensive Injury
DCO Viscera primary repair
Be diligent in evaluating the surrounding tissue for hematoma and ischemic changes.
DCO Thoracic , Indications for Thoracotomy
-Cardiac tamponade or other injuries identified on FAST
-Massive thoracic trauma or hemorrhage
-High likelihood of intrathoracic injuries
DCO Thoracotomy Cardiac Tamponade
-left anterolateral thoracotomy in the 4th or 5th intercostal space from the sternum to the lateral chest wall > curvilinear incision as one moves more posterior.
-If not doing a clamshell thoracotomy, the right chest should still be decompressed with a thoracostomy to rule out a concomitant pneumothorax.
Cardiac Tamponade > the pericardium should be opened first (before aortic cross-clamping) in a reverse T fashion to avoid injury to the phrenic nerve.
DCO Thoracotomy Direct Heart Injury
-Temporized with direct pressure, use of a skin stapler, or insertion and inflation of a Foley balloon.
-Formal closure can be attempted in the operating room with use of (pledgeted) sutures.
Care should be taken to avoid coronary arteries when performing therapeutic maneuvers.
DCO Thoracotomy Massive Pulmonary Hemorrhage
-Managed with anatomical (e.g., lobectomy ) or nonanatomic (wedge) resections.
-For massive bleeding or refractory hemorrhage >
hilar clamping or a hilar twist can be performed
the hilum of the affected lung is rotated 180 degrees. Division of the inferior pulmonary ligament up to the level of the inferior pulmonary vein is required for a hilar twist.
-Pneumonectomies should be avoided if possible > poor outcomes.
-In some cases, packing of the chest may be undertaken to facilitate transfer to the ICU > monitor peak pressures
DCO Vascular
-Some large vessels cannot be ligated Like
suprarenal IVC, SMA and SMV , and iliac arteries
-Either directly repaired or a temporary shunt placed for up to 3 days to restore flow.
Allowing period of resuscitation and then definitive repair or transfer to a higher level of care.
Shunts Secured with heavy Sutures
No Vessel Debridement till Definitive repair
Doppler used to check Flow
After Vessel Repair no Adequate Back Flow
-Use embolectomy balloon catheter to rule out presence of thrombus or embolus.
-Systemic heparinization should be avoided
-Heparinized saline can be used to flush the proximal and distal vessels
DCO Vascular After Repair after ischemia ?
May need Fasciotomy
DCO Pelvic Hematoma
-left alone or managed with interventional radiology
-unless there is an expanding or pulsatile hematoma
Small Vessels that can be ligated
Smaller vessel injures
the mesentery, external iliac, or even the infrarenal IVC, can be ligated
Aim of Post Op Care for DCO
reversing coagulopathy, hypothermia, and acidosis
‘the lethal triad’
DCO Coagulopathy Cause and Treatment
-caused by crystalloid fluids that dilute coagulation factors.
-The use of a 1: 1: 1 transfusion strategy between pRBCs, plasma, and platelets.
-Transfusion should be continued and guided by full coagulation panel and thromboelastogram (TEG)
TEG > assess which factors are needed and guide any further transfusion requirements.
-The use of whole blood resuscitation is regaining popularity for use in resuscitation.
Hypothermia in Trauma Setting
1- Mild hypothermia is 36 ° C to 34 ° C
2- Moderate is 34 ° C to 32 ° C
3-Severe hypothermia is < 32 ° C.
Leads to coagulopathy > decreased enzyme activity, platelet function, and increased fibrinolytic activity.
How to treat hypothermia in Trauma
-Warm IV Fluids
-bear huggers
-drying the patient
-warm blankets
-cavity lavage (intraperitoneal, intrathoracic)
-in the most extreme: extracorporeal warming through cardiopulmonary bypass.
Acidosis , Causes , effect and treatment
- A result of hypoperfusion causing a lactic acidosis
-Advantages, such as improved dissociation of oxygen from hemoglobin
-Acidosis effect > decreased cardiac contractility and poor function of vasopressors.
Treatment with sodium bicarbonate > temporizing measure , does not treat the underlying cause
Caution with the use of sodium bicarbonate ?
-Lead to an increase in CO2 levels that may lead to respiratory acidosis if CO2 elimination cannot be increased (usually through increasing minute ventilation on the ventilator)
Second Look Operation, When and What to Do
-Within 24 to 48 hours (unless clinically indicated earlier)
-Reexamine for missed injuries and definitive repairs of hollow viscous, vascular, or other injuries.
-Counts during damage control laparotomy, especially if packing was left, are often inaccurate.
An abdominal x-ray should be obtained to rule out any retained foreign objects.
