damage control surgery
TRANSCRIPT
DAMAGE CONTROL SURGERY DAMAGE CONTROL SURGERY IN ABDOMINAL TRAUMAIN ABDOMINAL TRAUMA
Zeka
CONTENTSCONTENTS
- The principles in Damage Control surgery- When to decided from standard surgical approach to
damage control surgery- Preparation of the patient- Approach of organ injuries- Complications- Re- laparatomy- Case- Referrences
DAMAGE CONTROL SURGERYDAMAGE CONTROL SURGERY
MULTIPLE TRAUMA PATIENTS ARE MORE LIKELY TO DIE FROM THEIR INTRAOPERATIVE METABOLIC FAILURE THAT FROM A FAILURE TO COMPLETE OPERATIVE REPAIRS
DAMAGE CONTROL SURGERYDAMAGE CONTROL SURGERY
MULTIPLE TRAUMA PATIENTS DIE FROM A TRIAD:
COAGULOPATHY
METABOLIC ACIDOSIS
HYPOTHERMIA
DAMAGE CONTROL SURGERYDAMAGE CONTROL SURGERY
STANDARD SURGICAL APPROACH
DAMAGE CONTROL APPROACH
It is better to cure in more phases than to kill in one …
DAMAGE CONTROL SURGERYDAMAGE CONTROL SURGERY
PRINCIPLES
1. CONTROL OF HAEMORRHAGE
2. PREVENTION OF CONTAMINATION
3. PROTECTION FROM FURTHER INJURY
DAMAGE CONTROL SURGERYDAMAGE CONTROL SURGERY
HYPOTHERMIA
Trauma patients are hypothermic due to enviromental conditions at the scene.Inadequate protection, IV fluid administration, and blood loss worse hypothermia.Shock leads to decreased cellular perfusion and inadequate heat production.Hypothermia has multiple effects on the bodyfuncions and exacerbates coagulopathy.
DAMAGE CONTROL SURGERYDAMAGE CONTROL SURGERY
ACIDOSIS
Shock leads to decreased cellular perfusion, anaerobic metabolism and the production of lactic acid.This leads to profund metabolic acidosis which promotes coagulopathy.
DAMAGE CONTROL SURGERYDAMAGE CONTROL SURGERY
COAGULOPATHY
-Hypothermia, metabolic acidosis and massive
blood transfusion lead to coagulopathy.-Coagulopathy worsen haemorrhagic shock
and in turn it worsens hypothermia and acidosis, prolonging the vicious circle.
WHEN TO DO DAMAGE WHEN TO DO DAMAGE CONTROL SURGERYCONTROL SURGERY
STANDARD SURGICAL APPROACH
DAMAGE CONTROL APPROACH
- pH below 7.2- Core temperature below 32/ 34 C- More than 5 transfusion
?
Do not wait !!
DAMAGE CONTROL SURGERYDAMAGE CONTROL SURGERY
PREPARATION
These patients should be transferred rapidly to the OR.All investigations that will not immediately affectpatient management should be deferred.These patients require operative control of haemorrhage and simultaneous vigorous resuscitation with blood and clotting factors. All fluids should be warmed and the patient covered and actively warmed as possible.
DAMAGE CONTROL SURGERYDAMAGE CONTROL SURGERY
LAPAROTOMY
The incision should be made from the xiphoid to the pubis. Opening the abdomen may result in dramatic haemorrhage and hypotension, control is initially achieved with multiple abdominal packs. If there is continued haemorrhage with packs in place, aortic control may be necessary.
DAMAGE CONTROL SURGERYDAMAGE CONTROL SURGERY
LAPAROTOMY
Aortic control is generally achieved at the diaphragmatic hiatus with blunt finger dissection and finger pressure by an assistant followed by aortic clamping.
DAMAGE CONTROL SURGERYDAMAGE CONTROL SURGERY
LAPAROTOMY
.The next step is to identify the source of bleeding..Examination of the abdomen must be complete..Immediate control of haemorrhage is with direct blunt pressure using the surgeon hands or abdominal packs..Vessels which can not be ligated without loss of life/limb are treated with indwelling shunts
DAMAGE CONTROL SURGERYDAMAGE CONTROL SURGERYLAPAROTOMY
LIVER, 1
The basic technique for control of hepatic hemorrhage is peri-hepatic packing.
DAMAGE CONTROL SURGERYDAMAGE CONTROL SURGERYLAPAROTOMY
LIVER, 2
The liver parenchyma can be compressed manually initially, followed by ordered packing in the anteroposterior plane.Even retrohepatic venous and IVC injuries may be controlled in this manner.The patient with hepatic packing should be considered for transfer to the angiography suite ( if applicable) immediately after operation to identify and control with embolization any arterial haemorrhage.
DAMAGE CONTROL SURGERYDAMAGE CONTROL SURGERYLAPAROTOMY
SPLEEN
Splenectomy is the treatment of choice for spleen injuries in this setting.
Attempts at splenic conservation are too time-consuming and prone to failure.
DAMAGE CONTROL SURGERYDAMAGE CONTROL SURGERYLAPAROTOMY
RETROPERITONEUM
Non-expanding, stable retroperitoneal and pelvic hematomas should not be explored and may be treated with abdominal packing. Subsequent angiographic embolization may be required.Only expanding hematomas require evacuation and exploration for serious vascular injury.
DAMAGE CONTROL SURGERYDAMAGE CONTROL SURGERY
LAPAROTOMYGASTROINTESTINAL TRACT, 1
Once control of haemorrhage has been obtained, prevention of contamination is achieved by the rapidly closure of hollow viscus injury. This may be definitive if there are only small enterotomies requiring primary suture. With extensive damage to the bowel it is wiser to resect non-viable bowel and close ends, leaving them in the abdomen for anastomosis at the second procedure.
DAMAGE CONTROL SURGERYDAMAGE CONTROL SURGERY
LAPAROTOMYGASTROINTESTINAL TRACT, 2
Ileostomies or colostomies should preferably not be performed in a damage control setting, especially if the abdomen is to be left open, as control of contamination is almost impossible.
DAMAGE CONTROL SURGERYDAMAGE CONTROL SURGERYLAPAROTOMY
PANCREAS
Minor pancreatic injuries require no treatment.In case of massive injuries, the pancreas should be debrided only, because patients will not survive complex operation such as pancreaticoduodenectomy.
DAMAGE CONTROL SURGERYDAMAGE CONTROL SURGERYLAPAROTOMY
ABDOMINAL CLOSURE
Abdominal closure is rapid and temporary. The abdomen should be left open as a laparostomy with a bag or vacuum-pack technique to avoid abdominal compartment syndrome.
DAMAGE CONTROL SURGERYDAMAGE CONTROL SURGERYLAPAROTOMY
ABDOMINAL CLOSURE
DAMAGE CONTROL SURGERYDAMAGE CONTROL SURGERYLAPAROTOMY
ABDOMINAL CLOSURE
DAMAGE CONTROL SURGERYDAMAGE CONTROL SURGERYLAPAROTOMY
ABDOMINAL CLOSURE
COMPLICATIONS OF COMPLICATIONS OF Damage control SurgeryDamage control Surgery
Failure to recognize non-coagulopathic hemorrhage which leads to exsanguination
Abdominal compartmental syndrome which leads to multi organ failure
Formation of enteric fistulas esp in pts with M.O.F and open abdomens for a long time
ARDS, intraabdominal abcesses, sepsisMortality at 60%
DAMAGE CONTROL SURGERYDAMAGE CONTROL SURGERY
CRITICAL CARE
The priority of the critical care phase of treatment is rapid reversal of metabolic failure. The patient must be actively warmed, coagulopathy and acidosis must be corrected.
The next 24-48 hours are crucial if the patient requires a second surgical procedure.
DAMAGE CONTROL SURGERYDAMAGE CONTROL SURGERY
REOPERATION
Timing of reoperation is crucial. There is a window of opportunity between correction of metabolic failure and the onset of a multiple organ failure.This window occurs at 24-48 hours after the first procedure
DAMAGE CONTROL SURGERYDAMAGE CONTROL SURGERY
REOPERATION
The principles of reoperation are:
• removal of packs• complete inspection of the abdomen• haemostasis• restoration of intestinal integrity• abdominal closure
DAMAGE CONTROL SURGERYDAMAGE CONTROL SURGERY
REOPERATION
Packs, especially around the liver or spleen, should be removed cautiously as removal may lead to further bleeding. Soaking the swabs may aid this process.Any intestinal repair should be inspected and repair with anastomosis undertaken.Copious washout should be performed and the abdomen closed with standard technique.
DAMAGE CONTROL SURGERYDAMAGE CONTROL SURGERY
CASECASE
B.M, D.O.A 28/10/13Hx : hit by a lorry on the left side of
abdomen, no L.O.CExam: RR 22, PR 101, Bp 80/50, GCS
15/15, Hb 10, WBC 17.8FAST: liver trauma
Mx: Hrly vitals signs, repeat FBC 4 hrly30/10/13: RR 22, Bp 123/65, PR 91, Hb 7.7
and signs of peritoneal irritation31/10/13: laparatomy, 4000cc of blood
harvested, packing of liver injury4/11/13: re- lap, repair of liver injury,
sphincteroplasty5/11/13: multi organ failure6/11/13 : Died
referencesreferences Physiologic rationale for abbreviated laparotomy. Surg Clin North
Am. (1997);77:779–782. [PubMed] ‘Damage control’: An approach for improved survival in
exsanguinating penetrating abdominal injury. J Trauma. (1993);35:375–383. [PubMed]
The abdominal compartment syndrome. Surg Clin North Am. (1996);76:833–842. [PubMed]
Delayed gastrointestinal reconstruction following massive abdominal trauma. J Trauma. (1993);34:233. [PubMed]
Planned reoperation for trauma: A two year experience with 124 consecutive patients. J Trauma. (1994);37:365. [PubMed]