Damage Control


Three phases

i) abbreviated operation to control beleeding and contamination by rapid maneuvers
- ie packing, vessel ligation, shunting, bowel resection and stapling closed, open abdomen
ii) ICU for aggressive fluid resuscitation, rewarming and coagulation correction.
iii) return to operating room for definitive repair; may need more than one operation


Damage Control / Pack & Run

Severe shock, hypothermia, coagulopathy: proceeding with anything other than the most life-threatening of injuries is a risky proposition.
In this setting, only those procedures immediately life-saving are performed.
Packs are left to stop bleeding.
- bowel injuries are resected with staplers or tied off with umbilical tapes.
No stomas or drains are placed (packing less effective).
Returned to ICU for warming and resuscitation.

Predictors of Needing Damage Control

Decide early in Op
Temp <34
pH <7.2
Bicarb <15 mmol/L
Total fluids >15L






Jerome's Notes on Damage Control

Principle:

delay additional surgical stress until the pt the more favourable status

so        Arrest bleeding

Limit peritoneal contamination and secondary inflammatory process

Enclose the abdominal content to avoid heat, fluid, protein loss from abdomen

 

Indication:

Beware hypothermia, coagulopathy and acidosis

            Inability to achieve haemostasis because of coagulopathy

            Inaccessible major venous injury

Demand for control of a life-threatening extra-abdo injuries: head/thorax/pelvis

Inability to close the abdomen

Staged for reassess the abdo because of viability of abdominal content

Markers of instability

· Sys BP <75

· Base XS > -8

· pH < 7.25

· Temp <35°C ÷ »85% mortality

· ISS > 25

- blood transfusion >10u; loss >4L; >10L in OR

- associated life-threatening injuries at 2 anatomical locations

Technique

<2hours

Laparotomy

· Should take <1hour

· Principles of Trauma laparotomy

— Rapid control of haemorrhage & enteric contamination

— Careful inspection of injuries

— Definitive repair of injuries

· Principles of damage control laparotomy

— Haemorrhage control

— Contamination control

— Pack & close

2-36 hours

— Rewarm

— Physiological correction

24-48 hours

· Remove packs

· Definitive surgery

1-8/52

· Definitive reconstruction