Arnanda Noor

M. Adam Pribadi

Damage Control Surgery

Damage control operations are performed in injured patients with profound hemorrhagic shock and preoperative or intraoperative metabolic sequelae that are known to adversely affect survival

Definition

The Lethal Triad

Acidemia

Coagulopathy

Hypothermia

66% injuried patients were hypothermic (<360 C)

23% were severely hypothermic (<340 C)Hypothermic shock leads to decreases on

oxygen consumption dan oxygen deliveryCauses:

- vasodilation- undressing the patient- unheated infusion fluid

Hypothermia

Maneuvers to prevent or reverse hypothermia

Prolonged hypovolemic shock produces a state of persistent metabolic acidosis in the patient with major trauma.

Acidemia

The historic replacement of volume losses with large amounts of crystalloid solutions and cold-packed red blood cells (PRBCs) leads to clotting abnormalities secondary to dilution, deficiency of clotting factors, and hypothermia.

Coagulopathy

Thoracic TraumaPenetrating thoracic wound and systolic blood

pressure <90 mmHgPericardial fluid on surgeon-performed

ultrasound after blunt or penetrating thoracic trauma

S/p emergency department thoracotomy for penetrating thoracic wound

Indications

Abdominal or Pelvic TraumaPenetrating abdominal wound and systolic

blood pressure <90 mmHgBlunt abdominal trauma, systolic blood

pressure <90 mmHg, and peritoneal fluid on surgeon-performed ultrasound or gross blood on diagnostic peritoneal tap

Closed pelvic fracture, systolic blood pressure <90 mmHg, and peritoneal fluid on surgeon-performed ultrasound or gross blood on diagnostic peritoneal tap

Open pelvic fracture

Indications

Trauma to an ExtremityShotgun wound to femoral triangle of thighMangled extremity from blunt trauma

GeneralEmergency laparotomy to be followed by

emergent craniotomy for compressive lesion, emergent thoracotomy for repair of ruptured descending thoracic aorta, or therapeutic embolization of pelvic bleeder related to fracture

Indications

Intraoperative Indications

1. Limited operative for control of hemorrhage and contamination

- control of hemorrhage from the heart or lung- conservative management of injuries to solid organs- resection of major injuries to the gastrointestinal tract

without reanastomosis- control of hemorrhage from major arteries and veins in the

neck, trunk, or extremities- packing of organs or spaces to control the inevitable

coagulopathy- use of an alternate closure of a cervical incision,

thoracotomy, laparotomy, or site of exploration of an extremity.

Stages of Damage Control

2. Resuscitation in the SICU- rewarming of the hypothermic patient- restoration of a normal cardiovascular state

by the infusion of fluids and blood and the use of inotropic and related drugs

- correction of residual coagulopathy after hypothermia is reversed

- supportive care for stunned lungs and kidneys.

Stages of Damage Control

3. Reoperation- completion of definitive repairs- search for missed injuries- formal closure of the incision, if possible

Stages of Damage Control

The abdominal compartment syndrome refers to the decreased blood flow to the body wall and abdominal organs and secondary pressure effects on the respiratory, cardiovascular, and central nervous systems when the intra-abdominal pressure rises above a critical level.

ABDOMINAL COMPARTMENT SYNDROME

Grading of Abdominal Compartement Syndrome