DAMAGE CONTROL IN TRAUMA

AND THE PROSPECT OF DAMAGE CONTROL RESUSCITATION VERSION 07-07

Two types of damage control (since 2004 after

starting Iraqi large scale conflict)
 DAMAGE CONTROL SURGERY
 Stop bleeding
 Stop contamination
 Temporary abdominal closure
 DAMAGE CONTROL RESUSCITATION
 Early management of coagulopathy
 And other component of lethal triad

MANAGEMENT TREE FOR BLEEDING INTRAPERITONEAL

INJURIES
Hemodynamically Hemodynamically
ATLS protocol
stable unstable

Hollow viscus or
CT scan
Diaphragmatic injuries US-fast

Contrast extravasation celitomy

If:
Acidosis
Hypothermia
Ongoing > 8 PRBC
Angiography-embolization
bleeding coagulopathy

N.O.M D.C.S

NOM: nonoperative management

DCS:damage control surgery
US : Ultrasound
PRBC: Pached red blood cells
Chiara, O, Cimbanasi S and Vesconi S : Critical Bleeding in Blunt Trauma
Patients in 2006 Year Book of Intensive Care and Emergency Medicine,
Springer 2006
 MANAGEMENT TREE OF COMPLEX INJURIES OF THE
EXTREMITIES
Extremity injury

Stop hemorrhage

Check for:
Peripheral perfusion
Motor/sensory function
Bone integrity
Soft tissue integrity

Three or more
Components
involved

DCO:
no yes Damage control
orthopedics
Systemic injuries
With higher priority DCO
successful unsuccessful
no yes

Definitive Early
repair amputation
Chiara, O, Cimbanasi S and Vesconi S : Critical Bleeding in Blunt Trauma Patients in 2006 Year Book of Intensive Care and Emergency Medicine,Springer 2006

PROTOCOL FOR THE USE OF rFVIIa IN

CRITICAL HEMORRHAGE IN THE BLUNT TRAUMA PATIENT

Traumatic bleeding in patient on

Non-mechanical bleeding in:
 Pelvic ring disruption
pre-injury anticoagulant therapy
 Intraperitoneal injury
 Injury of extremities and
 Multiple transfusions (> 8 PRBC
within 4 h)

1. Infuse FFP 10 ml/kg Still rFVIIa 90 µg/kg

2. Give PLT (> 50.000) bleeding
3. Correct fibrinogen Still bleeding after 120 min
(>50 mg/dl)
4. Correct pH (>7.2)
Still
5. Check again for
surgical bleeding rFVIIa 90 g/kg
bleeding

Exclude (futile administration) If:

INR: International Normalized Ratio 1. pH < 7.1
FFP: Fresh Frozen Plasme 2. Lactate > 13 mmol/l
PLT: Platelets 3. Previous or impending CPR
CPR: Cardio pulmonary resuscitation

Chiara, O, Cimbanasi S and Vesconi S : Critical Bleeding in Blunt Trauma Patients in 2006 Year Book of Intensive Care and Emergency Medicine, Springer 2006
 TRAUMA IS MULTISYSTEM DISEASE AND IMMUNE DYSFUNCTION DISEASE
Three peaks of trauma related deaths

First peak
Laceration of brain
Third peak
brainstem
Sepsis
aorta
Multi organ failure
spinal cord
Second peak
heart
Extradural
Subdural
Hemopneumothorax
Pelvic fractures
Long bone fractures
Abdominal injuries
DEATHS

s s
eek eek
2w 4w
1 hour 3 hours

DSTC / KT- IKABI

Damage Control Sequence
PART III - OR
PART
pack III - OR
removal
pack removal
definitive repair
PART I - OR definitive repair
PARThemorrhage
control I - OR
controlcontamination
control hemorrhage
control contamination
intraabdominal packing
intraabdominal
closurepacking
temporary
temporary closure
Transfer problems
PART II - ICU
PART
core II - ICU
rewarming
core rewarming
correct coagulopathy
correct coagulopathy
maximize hemodynamics
Transfer problems maximize support
ventilatory hemodynamics
ventilatory
injury support
identification
injury identification
(tertiary survey)
(tertiary survey)
DAMAGE CONTROL
 Deciding on an optimal time to return to the operating room
involves making some judgment calls
 The time period may be only 2 to 6 hours, although it may
be necessary to delay to return to the OR for as long as 24
to 48 hours in order to attain a stable physiologic state

CONVENTIONAL TRAUMA LAPAROROTOMY FOR

ESSENTIAL PARTS
1. Control of Bleeding
2. Identification of Injury
3. Control of Contamination
4. Reconstruction

Operative Management Of Small Bowel Fistulae Associated With

Open Abdomen