Damage Control Surgery Damage Control Surgery

Damage Control Surgery Damage
Damage
Control
Control
Surgery
Surgery
Francesco Enrichens MD FACS
Chief Department of Surgery
CTO Hospital Turin, Italy
Chief EMS Regione Piemonte
Francesco Francesco Enrichens Enrichens MD FACS MD FACS
Chief Department Chief Department of of Surgery Surgery
CTO Hospital CTO Hospital Turin Turin, , Italy Italy
Chief Chief EMS Regione Piemonte EMS Regione Piemonte
The Fourth Mediterranean Emergency Medicine Congress
Sorrento 15-19 September 2007
The The Fourth Mediterranean Emergency Fourth Mediterranean Emergency Medicine Medicine Congress Congress
Sorrento 15 Sorrento 15- -19 19 September September 2007 2007
Damage Control Surgery Damage Damage Control Control Surgery Surgery
The Fourth Mediterranean Congress on Emergency Medicine
The The Fourth Mediterranean Congress Fourth Mediterranean Congress on on Emergency Emergency Medicine Medicine
Piemonte Region:
Torino area:
2,2 milioni people
1 Dispatch center
About 1 millions calls/year
217.453 EMS runs/year
The background The background
The background
4,4 milions people
8 Dispatch centers
2 millions calls/year
423.728 EMS runs/year
Hospital and EMS network May 2006
Medical facilities (DEA)
41
41
41
24%
24% 24%
12%
12% 12%
1%
1% 1%
2%
2% 2%
2%
2% 2%
12%
12% 12%
3%
3% 3%
8%
8% 8%
10%
10% 10%
TRAUMA
TRAUMA TRAUMA
26%
26% 26%
EMS runs 423.728
Year 2006
Year 2006
Other Other
Cardiovascular Cardiovascular
G.U. G.U.
Poisonong Poisonong
Malignancy Malignancy
Neurological Neurological
Not identified Not identified
Behavioral Behavioral
Respiratory Respiratory
Trauma Trauma
11,5% 11,5% 11,5% 11,5%
11,5% 11,5% 11,5% 11,5% CODE 0 CODE 0 CODE 0 CODE 0 CODE 0 CODE 0 CODE 0 CODE 0
75,1% 75,1% 75,1% 75,1%
11,6% 11,6% 11,6% 11,6%
1,6% 1,6% 1,6% 1,6%
0,2% 0,2% 0,2% 0,2%
118 EMS Pts. Severity
score
score
score
DEANET EVOLUTION
IMAGING TRANSMISSION
IMAGING TRANSMISSION IMAGING TRANSMISSION
Head trauma
AMI/CVA
Burns
Strokes
Trauma
System IT development System IT development
System IT development
INTERHOSPITAL NETWORK
Consulting activity &
Transfer to treatment
Consulting activity
Consulting activity
&
&
Transfer
Transfer
to
to
treatment
treatment
SINCE 1997:
1. more 8459 cons. completed
2. 80% of transport avoided
3. 57% of pts. transferred underwent
surgery
4. more 250.000 images handled
5. 26% pts treated at home without
hospitalization
SINCE 1997: SINCE 1997:
1. 1. more 8459 cons. completed more 8459 cons. completed
2. 2. 80% of transport avoided 80% of transport avoided
3. 3. 57% of pts. transferred underwent 57% of pts. transferred underwent
surgery surgery
4. 4. more 250.000 images handled more 250.000 images handled
5. 5. 26% pts treated at home without 26% pts treated at home without
hospitalization hospitalization
Socio-economic sustainability: some
relevant results
Socio
Socio
-
-
economic sustainability: some
economic sustainability: some
relevant results
relevant results
Trauma:
Trauma:
383.540
383.540
Trauma
Trauma
year mean
year mean
: 95.885
: 95.885
Trauma day
Trauma day
mean
mean
:
:
263
263
EMS
EMS
runs
runs
118:
118:
1.598.419
1.598.419
Year mean
Year mean
: 399.605
: 399.605
Day
Day
mean
mean
: 1.095
: 1.095
24%
Analysis Years
Analysis Years
:
:
2003
2003
2004
2004
2005
2005
-
-
2006
2006
0 10000 20000 30000 40000
cod. 0
cod. 1
cod. 2
cod. 3
cod. 4
2006
2005
2004
2003
"Trauma on the road Regione Piemonte "Trauma
"Trauma
on the road Regione Piemonte

on the road Regione Piemonte
Ospedale CTO Ospedale CTO
Trauma Center Trauma Center
Spine Spine unit unit and and rehab rehab
85000
90000
95000
100000
2
0
0
2
2
0
0
3
2
0
0
4
2
0
0
5
2
0
0
6
Number
Number
of trauma per
of trauma per
year
year
Hip fractures on total
trauma patients:
-17,34%
Pelvic fractures on total
trauma patients:
+21,54%
January
January
-
-
December
December
2006
2006
Severe trauma
Severe trauma
ISS
ISS
= or > 16
= or > 16
o o
324
324
patients
patients
o
o
239 male
239 male
o
o
85
85
female
female
o
o
Mean age
Mean age
46
46
o
o
Admitted to
Admitted to
ICU 70%
ICU 70%
Damage Damage control control is is the the term used term used in in
the the Merchant Merchant Marine Marine, , maritime maritime
industry industry and and Navies Navies for for the the
emergency emergency control of control of situations situations that that
may hazard may hazard the the sinking sinking of the of the ship ship
..
..
Simple measures
Simple measures
may
may
stop
stop
flooding
flooding

ER
ER
OR Death
OR ICU OR ICU
Time
Conventional surgical
Conventional surgical
treatment
treatment
Damage
Damage
Control
Control
treatment
treatment
ER
ER
OR Death
OR ICU OR ICU
It
It
s better to
s better to
cure in more
cure in more
phases than to kill
phases than to kill
in one
in one
Acidosis
Acidosis
Coagulopathy
Coagulopathy
Lethal triad Lethal triad
Death
Death
Hypothermia
Hypothermia
A mathematical model predicts a heat loss rate
during a trauma laparotomy of 4,6 C per hour
A
A
mathematical
mathematical
model
model
predicts
predicts
a
a
heat loss
heat loss
rate
rate
during
during
a trauma
a trauma
laparotomy
laparotomy
of
of
4,6
4,6

C per
C per
hour
hour
Despite global warming
Despite global warming
A core
A core
temp
temp
below
below
32
32

C
C
during
during
trauma
trauma
laparotomy
laparotomy
in
in
considered
considered
universally
universally
fatal
fatal
Concepts
Concepts
:
:
1.
1.
Rapid laparotomy
Rapid laparotomy
2.
2.
Bleeding
Bleeding
control
control
3.
3.
Spillage
Spillage
control
control
4.
4.
Temporary abdominal
Temporary abdominal
closure
closure
(
(
avoiding
avoiding
tension
tension
)
)
Patients likely to need damage Patients likely to need damage control control surgery surgery
Thoracic Thoracic trauma trauma
Penetrating injury Penetrating injury and SBP < 90 and SBP < 90 mmHg mmHg
Pericardial fluid Pericardial fluid on FAST on FAST
Emergency Emergency room room thoracotomy thoracotomy
Abdominal Abdominal and and pelvic pelvic trauma trauma
Penetrating injury Penetrating injury and SBP < 90 and SBP < 90 mmHg mmHg
Blunt Blunt trauma and trauma and peritoneal fluid peritoneal fluid on FAST and SBP < on FAST and SBP <
90 90 mmHg mmHg
Closed pelvic fracture Closed pelvic fracture and and peritoneal fluid peritoneal fluid on FAST on FAST
and SBP < 90 and SBP < 90 mmHg mmHg or or gross blood gross blood on DPL on DPL
Open Open pelvic fracture pelvic fracture
Patients likely to need damage Patients likely to need damage control control surgery surgery
Extremity Extremity trauma trauma
Shotgun wound to femoral triangle Shotgun wound to femoral triangle
Mangled extremity Mangled extremity
General General trauma trauma
Emergency laparotomy to be followed by emergent Emergency laparotomy to be followed by emergent
craniotomy craniotomy or or emergent thoracotomy emergent thoracotomy or or emergent emergent
angiographic embolization angiographic embolization of of fracture associated fracture associated
pelvic bleeders pelvic bleeders
Abdominal
Abdominal
trauma:
trauma:
Hemodynamically normal
Hemodynamically normal
Hemodynamically unstable
Hemodynamically unstable
NOM
NOM
Laparotomy
Laparotomy
Angiography
Angiography
FAST POS
FAST POS
Pelvis stable
Pelvis stable
FAST NEG
FAST NEG
Pelvis unstable
Pelvis unstable
FAST NEG
FAST NEG
Pelvis stable
Pelvis stable
FAST POS
FAST POS
Pelvis unstable
Pelvis unstable
Hemodynamic instability
FAST POS
FAST POS
Pelvis unstable
Pelvis unstable
Damage
Damage
Control
Control
Surgery
Surgery
Surgery vs
Surgery vs
non operative
non operative
management
management
is
is
a
a
surgical
surgical
decision
decision
and
and
must be
must be
made
made
by
by
a
a
surgeon
surgeon
AAST -OIS LIVER

GRA DE I
Hematoma: su bcaps ular < 10% surf ac e area.
Laceration: c apsu lar te ar, < 1 cm parenc hyma l de pth .

GRA DE II
Hematoma: subcapsular 10-50% sur face area.
Int raparenchim al < 10 cm diamet er
L acerati on: 1-3 cm parenchymal depth, < 10 cm l ength.

GRA DE III
Hematoma: subcapsular > 50% surf ace area or expandi ng,
rup tur ed sucapsul ar or i nt r apar enchymal hematoma.
Int raparenchym al hematoma > 10 cm or expandi ng.
L acerati on: > 3 cm parenchy mal depth, > 10 cm l ength.

GRA DE IV
L acerati on: par enchym al disr uption i nvo l vi ng 25- 75% of hepati c l obe
or 1 -3 Coui nauds segments in a singl e lo be.

GRA DE V
L acerati on: par enchym al disr uption i nvo l vi ng > 75% of hepat ic l obe or > 3
Co ui nauds segments i n a si ngl e l obe.
Vas cul ar: Juxtahepati c venous in j uri es i e. r etr ohepati c vena cava, maj or
hepatic veins.

Liver
Liver
trauma:
trauma:
Grade
Grade
I and II
I and II
often found during
often found during
laparotomy for other indications
laparotomy for other indications
(
(
ruptured
ruptured
spleen)
spleen)
Definitive treatment (no
Definitive treatment (no
touch
touch
,
,
DTC, Argon
DTC, Argon
beam coagulation
beam coagulation
,
,
topic haemostatics
topic haemostatics
, suture)
, suture)
Liver
Liver
trauma:
trauma:
Grade
Grade
III, IV and
III, IV and
V
V
definitive
definitive
treatment or
treatment or
damage
damage
control
control
Resectional debridment
Resectional debridment
,
,
perihepatic
perihepatic
packing
packing
,
,
baloon tamponade
baloon tamponade
,
,
Foley
Foley
catheter
catheter
tamponade
tamponade
Liver
Liver
trauma
trauma
years
years
1990
1990
-
-
2007
2007
Total 242
Total 242
patients
patients
From January
From January
1990
1990
to March
to March
1998 79
1998 79
patients
patients
From April
From April
1998
1998
to July
to July
2007 163
2007 163
patients
patients
Liver
Liver
trauma
trauma
years
years
2004
2004
-
-
2007
2007
85 85 patients patients
Low grade Low grade (I and II) 47 (I and II) 47 patients patients
High High grade grade (III, IV and V) 38 (III, IV and V) 38 patients patients
Operated Operated 29 29
Non Non operated operated 56 56
Liver
Liver
Trauma: 1990
Trauma: 1990
-
-
1998
1998
NOM
NOM
Failure
Failure
Surgery
Surgery
6.9
6.9
4.9
4.9
RTS
RTS
34
34
40
40
ISS
ISS
43
43
34
34
Age
Age
6/5
6/5
56/12
56/12
M/F
M/F
11
11
68
68
N
N

pts
pts
23.7
23.7
42.3
42.3
ISS
ISS
6.89
6.89
4.91
4.91
RTS
RTS
39.6
39.6
35.8
35.8
Age
Age
72/27
72/27
50/14
50/14
M/F
M/F
99
99
64
64 N
N

pts
pts
NOM
NOM
Surgery
Surgery
Liver
Liver
trauma: 1998
trauma: 1998
-
-
2007
2007
Liver
Liver
trauma:
trauma:
grading
grading
and
and
surgical
surgical
procedure
procedure
33 33 36 36 35 35 36 36 17 17 Total Total
6 6
6 6
4 4
8 8
3 3
3 3
3 3
V V
6 6
6 6
3 3
19 19
2 2
IV IV
2 2
1 1
25 25
3 3
4 4
III III
Caval Caval or or portal portal suture suture
Liver packing Liver packing
Resectional debridment Resectional debridment
II II I I
Major Major resection resection
Limited resection Limited resection
15 15 Suture Suture
8 8 5 5 DTC DTC Haemostatics Haemostatics
13 13 1 12 2 No No touch touch
Liver
Liver
trauma:
trauma:
grading
grading
and NOM (
and NOM (
years
years
2004
2004
-
-
2007)
2007)
54
54
30
30
24
24
Total
Total
0
0
0
0
0
0
V
V
7 7 4 4 3 3 IV IV
23 23 11 11 12 12 III III
21 21 13 13 8 8 II II
3 3 2 2 1 1 I I
Total Total 2005 2005- -2007 2007 2004 2004- -2005 2005 Grade Grade
19.28
19.28
35.58
35.58
ISS
ISS
7.1
7.1
6.2
6.2
RTS
RTS
35.7
35.7
48.2
48.2
Age
Age
60/23
60/23
12/4
12/4
M/F
M/F
83 (83.8%)
83 (83.8%)
16 (16.2%)
16 (16.2%) N
N

pts
pts
Success
Success
Failure
Failure
Liver
Liver
trauma: NOM of 99
trauma: NOM of 99
patients
patients
5 5 Caval Caval or or portal portal suture suture
2 2 Liver packing Liver packing
2 2 4 4 Resectional debridment Resectional debridment
NOM NOM Failure Failure Surgery Surgery
9 9 Major Major resection resection
2 2 Limited resection Limited resection
6 6 32 32 Suture Suture
3 3 DTC DTC Haemostatics Haemostatics
3 3 11 11 No No touch touch
Liver
Liver
trauma:
trauma:
surgical
surgical
procedure
procedure
1990
1990
-
-
1998
1998
Liver
Liver
trauma:
trauma:
surgical
surgical
procedure
procedure
1998
1998
-
-
2007
2007
1 1 Caval Caval or or portal portal suture suture
12 12 Liver packing Liver packing
5 5 Resectional debridment Resectional debridment
NOM NOM Failure Failure Surgery Surgery
2 2 Major Major resection resection
1 1 Limited resection Limited resection
8 8 16 16 Suture Suture
4 4 11 11 DTC DTC Haemostatics Haemostatics
4 4 16 16 No No touch touch
Liver
Liver
trauma:
trauma:
Hospital stay
Hospital stay
35
35
days
days
NOM
NOM
failure
failure
1998
1998
-
-
2007
2007
1990
1990
-
-
1998
1998
23
23
days
days
31
31
days
days
23
23
days
days
NOM
NOM
Surgery
Surgery
Surgery
Surgery
Liver Liver trauma: hospital stay and trauma: hospital stay and associated lesions associated lesions
LESIONE
ASSOCIATA
PRESENTE
LESIONE
ASSOCIATA
ASSENTE
FRATTURA DI BACINO
FRATTURA DI FEMORE
FR. TIBIA E/O PERONE
LESIONI SNC
PNX
EMOTORACE
LESIONI SPLENICHE
0
5
10
15
20
25
30
35
40
45
50
G
i
o
r
n
i

d
i

d
e
g
e
n
z
a
FRATTURA DI BACINO
FRATTURA DI FEMORE
FR. TIBIA E/O PERONE
LESIONI SNC
PNX
EMOTORACE
LESIONI SPLENICHE
Liver
Liver
trauma:
trauma:
Mortality
Mortality
28.9%
28.9%
70/242
70/242
1990
1990
-
-
2007
2007
Total
Total
3.0%
3.0%
46.8%
46.8%
Percentage
Percentage
3/99
3/99
67/143
67/143
Number
Number
1998
1998
-
-
2007
2007
1990
1990
-
-
2007
2007
Years
Years
NOM
NOM
Surgery
Surgery
Liver Liver trauma: trauma: grading grading and cause of and cause of death death
7 7
4 4
1 1
1 1
1 1
Other Other
Cause of Cause of death death % % Death Death Grade Grade
3 3 1 1 21 21 81 81 25/31 25/31 V V
2 2 1 1 11 11 38 38 18/47 18/47 IV IV
6 6 5 5 18 18 13/72 13/72 III III
5 5 2 2 3 3 16 16 11/67 11/67 II II
1 1 1 1 12 12 3/25 3/25 I I
Both Both CNS CNS Shock Shock
Dead Survived p value
O.I. S liver I.O.

3,8 1,2 2,7 1,2 1,03 X 10
-6
O.I. S. liver TC 1,9 1,4 2,3 1,1 0,22
ISS

46,6 11 ,2 29,3 13 ,3 3,65 X 10
-15
RTS

3,7 2,1 6,7 1,6 1,6 X 10
-15
Blood pressur e

57,1 51 ,2 110,7 2 5,8 1,64 X 10
-10
Heart rate 93,1 42 ,8 100,1 2 3,0 0,151
Hb

9,9 3,0 11,6 2,3 0,00032
Creatinin

1,2 0,3 1,1 0,3 0,0214
Run time to hospital 52,8 38 ,2 60,0 76 ,9 0,25
INR

1,9 1,1 1,4 0,4 0,00053
Ph art erial

7,2 0,2 7,3 0,1 0,037
GCS

6,2 4,6 12,3 3,9 4,38 X 10
-13
Age

38,2 18 ,8 33,1 14 ,6 0,04
Hemoperitone um (ml)

2673,3 1385,0 1306,9 1216,6 4,21 X 10
-9

Liver
Liver
trauma:
trauma:
mortality
mortality
and
and
surgical
surgical
procedure
procedure
0
10
20
30
40
50
60
70
80
90
100
M
o
r
t
a
l
i
t

%
1
Intervento eseguito
NO TOUCH
DEBRIDEMENT - DTC - AGENTI
EMOSTATICI
EPATORRAFIA
RESEZIONE ATIPICA
RESEZIONE ANATOMICA
MAGGIORE
RESEZIONE ANATOMICA
LIMITATA
LIVER PACKING
SUTURA VENA CAVA E/O VENE
PORTA
Liver
Liver
trauma: AST/ALT
trauma: AST/ALT
value
value
and
and
injury
injury
grade
grade
0
100
200
300
400
500
600
U
.
I
.
/
L
GRADO 1 GRADO 2 GRADO 3 GRADO 4 GRADO 5
AST
ALT
AB 17 AB 17 years years old old female female. . Hit Hit during during a a karate competition karate competition
Hemodynamically normal Hemodynamically normal. .
AB: Non Operative Management. CT AB: Non Operative Management. CT scan scan at 30 at 30 days days
Conclusions
Conclusions
:
:
N
N
on
on
O
O
perative
perative
M
M
anagement in
anagement in
all
all
hemodynamically normal patients
hemodynamically normal patients
irrespective
irrespective
of the
of the
grade
grade
of
of
lesions
lesions
D
D
amage
amage
C
C
ontrol
ontrol
S
S
urgery
urgery
in
in
hemodinamically abnormal patients
hemodinamically abnormal patients
,
,
mostly
mostly
in high
in high
grade lesions
grade lesions
or in
or in
patients with
patients with
a
a
heavy burden
heavy burden
of
of
injury
injury
In trauma
In trauma
surgery
surgery
simple things
simple things
work
work
Damage Control Surgery Damage
Damage
Control
Control
Surgery
Surgery
Thank You for your attention
Thank You for your attention

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Damage Control Surgery Damage Damage Control Control Surgery Surgery

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