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
