Current Concepts of Damage Control in Trauma Patients

1. Current Concepts of Damage Control in Trauma Patients Juan C Duchesne MD, FACS, FCCP, FCCM Associate Professor of Surgery Medical Director Tulane Surgical Intensive Care Unit Section of Trauma/Critical Care Surgery/Anesthesia/Emergency Medicine Spirit of Charity Hospital, New Orleans Louisiana

2. Objectives • Outline damage control resuscitation • Review the rationale for damage control • Results of damage control procedures • Outline methods of temporary closure • Discuss techniques of definitive closure

3. TRIANGLE OF DEATH Acidosis Hypothermia Coagulopathy Shock

4. Acidosis Acidosis correlates with depth of shock and degree of tissue injury. Initial base deficit > - 7.5 = poor prognosis Lactate levels > 5 also correlate with a poor outcome but take longer to obtain.

5. Onset of Coagulopathy 93% 35% Stone HH, et al:Ann. Surg.197:532-5, 1983. Brohi,K et al.: J. Trauma 54:1127-30, 2003.

6. Hypothermia Luna GK, et al: J. Trauma 27: 1014-1017, 1987. Jurkovich GJ, et al: J. Trauma 27:1019-24, 1987. Rutherford EJ, et al: Injury 29:605-8, 1998

7. Phases of Damage Control Phase I – Resuscitation in the ED Phase II – Damage Control in the OR Phase III – Stabilization in the ICU

9. Damage Control in ED – Phase I DON’T SKY DIVE!

10. The “Old” Face of Trauma Care Before Damage Control Resuscitation

11. The “New” Face of Trauma Care with Damage Control Resuscitation

12. “You don’t have to swell to be well” Charity Hospital Trauma Aphorism

13. Distribution of Trauma patients in NOLA-Blunt (42%), Penetrating (58%) 4.9% of patients had severe injury requiring > 10 U PRBC in 24 hours

14. Hemostatic / Low Volume Resuscitation (LVR) • Hybrid permissive hypotension • Minimization of crystalloids • LVR with: Hextend and hypertonic saline • Close PRBC/ FFP / platelets TRAUMA INDUCED COAGULOPATHY

15. Combat Data

16. J TRAUMA 2008

17. Damage Control in OR – Phase II • Rapid control of hemorrhage • Control of contamination • Packing bleeding organs • Temporary closure • Secondary resuscitation in the ICU • Definitive closure after physiologic reserve is restored Rotondo MF, et al: J Trauma 1993;35:375-83.

18. Temporary Closure • Skin approximation • Towel clips • Bogotá bag • Modified removable prosthesis • Vacuum Assisted Closure (VAC)

19. Bogotá Bag

20. Advantages Inexpensive Avoids compartment syndrome Minimizes heat & fluid loss Non-adherent Ease of re-exploration Disadvantages Loss of abdominal domain Evisceration Open Abdomen .

21. Vacuum Assisted Closure

22. Vacuum AssistedClosure Advantages Prevent loss of abdominal domain Decreased incidence of Abd. Compartment Syndrome Extend the time of temporary closure Early fascial closure Disadvantages Requires specialized equipment Cost Miller PR, et al: J Trauma 2002;53:843-9.

23. Operative Damage Control • The decision to pursue damage control should be made early based on major physiologic instability due to shock. • Damage control procedures should be rapid (i.e., 30 to 45 minutes). ?????

24. Damage Control in the ICU – Phase III DEATH TRIAD ACIDOSIS COAGULOPATHY HYPOTHERMIA

25. ICU CARE • Ventilatory Management • Secondary Resuscitation • Recognition of Complications • Abdominal compartment syndrome • Dehiscence • Abscess • Fistula

26. Abdominal Perfusion Pressure • APP = MAP – IAP • Normal > 50 - 60 mm Hg (Critical to perfusion of abdominal organs)

27. Rapid decrease in intra-abdominal pressure Rapid decrease in ventilatory requirements Reperfusion syndrome Decompressive Celiotomy

28. Definitive Closure Once the patient has been stabilized and physiologic reserve has been restored, steps should be taken for definitive closure.

29. Definitive Closure • Primary closure • Biological materials • Porcine small intestinal submucosa • Human acellular dermis (Alloderm) • Plastic surgery techniques • Tissue expanders • Flaps • Component separation

30. Advantages Absence of foreign body Decreased risk of infection, enterocutaneous fistula and recurrent wound problems Disadvantages Increased tension Possible ACS Primary Closure

31. Advantages Ideal for contaminated or infected wounds Disadvantages Extremely expensive ($25/cm2) Limited shelf life 4.5% recurrence rate Biological Materials • Porcine small intestinal submucosa • Human acellular dermis (Alloderm) .

32. Component Separation RM RM EO EO IO IO TA TA Ramirez OM, et al: Plast Reconstr Surg 1990;86:519-26.

33. Component Separation RM RM EO IO EO TA IO TA Ramirez OM, et al: Plast Reconstr Surg 1990;86:519-26.

34. Component Separation Ramirez OM, et al: PlastReconstrSurg1990;86:519-26.

35. Conclusions • Trauma-induced coagulopathy (TIC) is associated with increased mortality in trauma patients transfused with > 10U of PRBC during the first few hours after injury. • Early hemostatic resuscitation with a ratio of 1:1:1 (FFP : PRBC : Platelets) early after injury improves survival in trauma patients with TIC.

36. Operative Damage Control • The decision to pursue damage control should be made early based on major physiologic instability due to shock. • Damage control procedures should focus on control of bleeding and contamination.

37. Conclusions • Damage contol operations can be life- saving, but they need to be pursued early and performed rapidly • Stabilization in the ICU should focus on resuscitating shock and reversing acidosis, coagulopathy, & hypothermia.

38. Thanks!