Scribd Logo
Upload

Welcome to Scribd!

  • Damage Control An Approach For Improved.8

    Uploaded by

    Cristina Clim
    4 views9 pages
    bbb

    Original Title

    Damage Control an Approach for Improved.8

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Report this Document
    bbb

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Flag for inappropriate content
    4 views9 pages

    Damage Control An Approach For Improved.8

    Uploaded by

    Cristina Clim
    bbb

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Flag for inappropriate content
    of 9
    2582 /89/9509.0978909 00/0 ‘Tue JounNAL oF Taavaa Copy 1985 by Wallan &e Wiking ‘DAMAGE CONTROL’: AN APPROACH FOR IMPROVED SURVIVAL IN EXSANGUINATING PENETRATING ABDOMINAL INJURY Michael F. Rotondo, MD, C. William Schwab, MD, FACS, Michael D. McGonigal, MD, FACS, Gordon R. Phillips, I, MD, Todd M. Fruchterman, BA, Donald R. Kauder, MD, FACS, Barbara A. Latenser, MD, and Peter A. Angood, MD Definitive laparotomy (OL) for penetrating abdominal wounding with combined. vascular and visceral injury is difficult surgical challenge. Physiologic ‘derangements such as dilutional coagulopathy, hypothermia, and acidosis often preclude completion of the procedure. “Damage control” (DG), defined as initial ‘control of hemorrhage and contamination followed by intraperitoneal packing and rapid closure, allows for resuscitation to normal physiology in the intensive care unit land subsequent definitive re-exploration. The purpose of the study was to compare ‘the damage control technique with definitive laparotomy. Over a 3 1/2-year period, 46 patients with penetrating abdominal injuries required laparotomy and urgent {transfusion of greater than 10 units packed red blood cells for exsanguination. Medical records were retrospectively reviewed for degree and pattem of injury, probability of survival, actual survival, transtusion requirements for the preoperative ‘and postoperative phases, resuscitation and operative times, lowest perioperative temperature, pH, and HCO,, No significant differences were identified between 22 DL ‘and 24 DC patients and actual survival rates were similar (55% DC vs. 58% DL). However, ina subset of 22 patients with major vascular injury and two or more visceral injuries (maximum injury subset) otherwise similar to the overall group, ‘survival was markedly improved in patients treated with damage control (10 of 13, 77%") vs. DLM (1 of 8, 11%) (Fisher's exact test,“ p < 0.02) In preparation for return to the operating room, DC survivors averaged 8.4 units of packed red blood cells transfused and 10.3 units fresh frozen plasma over a mean ICU stay of 31.7 hours. Resolution of coagulopathy (mean prothrombin time/partal thromboplastin time 19.5/ 70.4 to 13.3/34.8), normalization of acid-base balance (mean pH/HCOs 7.37/20.6 to 17.42/24.2), and core rewarming (mean 33.2°C to 37.7°C) were achieved. All patients hhad gastrointestinal procedures at reoperation (mean operative time, 4.3 hours). We ‘conclude that damage control is a promising approach for increased survival in ‘exsanguinating patients with major vascular and multiple visceral penetrating ‘abdominal injuries. ‘THE TRADITIONAL APPROACH to penetrating in- jury of the abdomen has consisted of exploratory lapa- rotomy for immediate control of hemorrhage and con- tamination. If physiologic stability is maintained, defin- itive repair of all injuries can be accomplished after initial control has been established. This method of definitive laparotomy works well in the care of patients who have either a limited number of injuries, or visceral injuries without a major vascular injury. In fact, the trauma literature is replete with studies that describe various injuries managed in this manner." In general, these From the Division of Traumatology and Surgical Critical Car, Depart- ment of Surgery, Hospital ofthe Unversity of Pennsyvania, Paden, Penneytvana Presented atthe Fifty-second Annual Session ofthe American ASso- cation for the Surgery Of Trauma, September 17-19, 1992, Louise, Division of Traumatotogy and Surgical Critical Care, Hospital of the Unversity of Peansyivana, 3400 Spruce St, Phiadeiphia, PA 19104, patients have been injured with small-caliber, lower muz- zle velocity weapons that dissipate a small amount of energy with a smaller cavitation effect.° For penetrating abdominal injuries, this usually translates into a limited number of anatomic defects that can be successfully managed with relative ease in the traditional fashion. It has been apparent in our clinical practice for some time that the street weaponry and wounding patterns are changing.** We are frequently encountering patients ‘who have suffered multiple penetrations from rapid firing large-caliber weapons with higher muzzle velocity and altered ammunition. This results in greater energy trans- fers with greater cavitation and tissue disruption.” The severe multiple anatomic defects caused by these weap- ons are not as easily managed with the traditional method of definitive laparotomy. ‘The difficulty lies in the maintenance of physiologic stability during the struggle for surgical control of hem- 315 376 The Journal of Trauma orthage. Large amounts of crystalloid and blood are required to stave off hypovolemic shock. This has two immediate deleterious effects. The first, hypothermia, results in potentially lethal arrhythmias” as well as plate- let dysfunction.'*"" The second, depletion coagulopathy, ends in “nonsurgical” bleeding from washout of vital ‘coagulation factors and platelets."*"* Concomitant with, hypovolemic shock, inadequate tissue perfusion results in severe metabolic acidosis. Under these circumstances, hypothermia, coagulopathy, and acidosis render safe completion of the surgical procedure impossible and may lead to the demise of the patient."°"" In 1983, H. Harlan Stone described the use of an alternative approach in this situation. Rapid termina- tion of the laparotomy after intra-abdominal packing was performed with the onset of clinically apparent intraoperative coagulopathy. Interval laparotomy was undertaken for definitive surgery when the patient was more stable. Since then, others have reported on the use of this technique for hepatic injuries” and more re- cently for non-hepatic injuries." ‘We have applied a similar technique called “Damage control.” Damage control has three separate and distinct aspects. First, surgical control of hemorrhage and con- tamination is obtained as quickly as possible, definitive repairs are deferred, and the laparotomy is abruptly terminated. Temporary closure of the abdomen is per- formed after intra-abdominal packing (part 1). The patient is then brought to the intensive care unit (ICU) where core rewarming, correction of coagulopathy, and maximization of hemodynamic values takes place (part 1), When normal physiology has been restored, re-explo- ration is undertaken to complete the definitive surgical management of all intra-abdominal injuries (part III). ‘This study compared the efficacy of damage control with the traditional technique of definitive laparotomy as a means of managing exsanguinating penetrating in- juries to the abdomen with concomitant multiple visceral injuries. MATERIALS AND METHODS Patient Selection From February 1988 through July 1991, 2977 patients were ‘evaluated at the Hospital of the University of Pennsylvania, ‘an urban level I trauma center. Patients were included for study ‘who suffered penetrating injury resulting in exsanguination referable to the abdomen with a greater than 10 unit packed red cell transfusion requirement before completion or termins- tion of laparotomy. Patients with extra-abdominal sources of ‘exsanguination and those who underwent emergency depart- ment thoracotomy were excluded. Forty-nine patients met these criteria and the medical records were retrospectively reviewed. Two patients were eliminated for incomplete medical records and one patient was excluded because of a missed intra- abdominal injury explaining ongoing blood loss, leaving 46 Patients for study. September 1993 Resuscitation Phase Each patient was met in the trauma admitting area by a full resuscitation team directed by a trauma surgeon or trauma fellow. Resuscitations followed the American College of Sur- geons’ Committee on Trauma, Advanced Trauma Life Support Guidelines. At our institution, rapid sequence induction and ‘orotracheal intubation are employed for airway control at the discretion of the surgeon according to established guidelines.” In addition, warm crystalloid is administered through large- bore intravenous access using high-flow tubing and pressure ‘bags. Type O blood was available forall patients on admission and administered according to previously described proto- cols? A perfusion team was mobilized to the operating room for rapid infusion and blood salvage at the discretion of the senior surgeon. Operative Phase All patients were brought to a trauma-designated operating room maintained at 80°F and prepared in advance for emer- gency celiotomy. Twenty-two of the patients underwent defin- itive laparotomy. Definitive laparotomy, the standard approach to emergent celiotomy, was characterized by rapid evacuation of hematoma, four-quadrant laparotomy pecking, initial control ‘of hemorrhage and contamination, followed by definitive vase- ular, solid organ, and hollow viscus repair. In this group, efforts were made to complete all the technical aspects ofthe operation based on the judgment of the senior surgeon. Damage control wwas performed on 24 of the patients during the study period. ‘The first part of damage control consisted of emergent celi- tomy for evacuation of hematoma and four-quadrant packing. Initial control of hemorrhage was achieved with packing, liga- tion, or clamps for all vascular injuries. Hollow viscus injuries ‘were temporarily controlled with ligation, staples, or simple running suture. Definitive vascular repair was then completed when warranted. When in the judgment of the senior surgeon, signs of intraoperative coagulopathy developed, intraperitoneal packing was applied to sites of nonsurgical bleeding as well as persistently bleeding visceral injuries. The procedure was ter- ‘minated and remaining definitive repairs were deferred. Rapid temporary closure of the abdomen was achieved with towel clips or nonabsorbable monofilament suture in the skin, s ‘and fascia, or with a prosthetic silo (part I). Important factors entering the decision to terminate the procedure included the ‘multiplicity and severity of injury, patient core temperature, transfusion requirements, and myocardial electrical instability, Following closure, the patients were transferred to the sur- gical intensive care unit (SICU) for the second aspect of damage control (part II). Volume resuscitation was achieved with warm blood and crystalloid administered by standard techniques or with @ Level 1 infuser (Level 1 Technologies, Ine., Rockland, ‘Mass.). Core rewarming was accomplished by utilizing radiant hheat lights, heating blankets, and, occasionally, chest tube placement for warm saline pleural lavage. Electrolyte abnor- ‘malities, thrombocytopenia, and coagulation defects were aggressively corrected with’ replacement therapy guided by laboratory measurements. Patients were maintained with hemodynamic monitoring and mechanical ventilation. In antic- ipation of return to the operating room, patients were carefully examined for occult injury, and the appropriate radiographic examinations were performed in an attempt to fully elucidate all injuries. ‘When fully resuscitated, warm, and no longer coagulopathi patients were returned to the operating room for removal of packing and completion of definitive surgical procedures (part TID. This often included restoration of bowel continuity, colo tomy formation, debridement of solid organ injuries, and en- teral access tube placement. Vol. 35, No. 3 Data Collection and Anslysis ‘The medical records of these patients were retrospectively reviewed for the following: demographic information; degree and pattern of injury"; probability of survival" and actual survival; resuscitation, operative and intensive care unit time; physiologic measurements recorded in the perioperative period including blood pressure, acid-base status, temperature, coag- ulation status; fluid and'blood product requirements. Postop- ‘erative surgical complications were also reviewed. Definitive laparotomy patients were compared with damage ‘control patients using the Student’ test. A subset of patients from each group who satisfied the criteria of the presence of ‘one or more major vascular injuries with two or more visceral injuries (the maximum injury subset), were compared using Fisher's exact test. A major vascular injury was defined accord. ing to the Penetrating Abdominal Trauma Index (PATD).” Solid organ and hollow viscus injuries were also classified in ‘this manner and then grouped together as visceral injuries. RESULTS Overall Group Demographics and Survival. The average age of patients in the study was 31 years. Only one patient was female and only 9 of 46 patients (19.6%) suffered stab ‘wounds. For the 22 patients in the definitive laboratory group, the mean Revised Trauma Score (RTS) was 6.44 with an Injury Severity Score (ISS) of 22.9. Application of TRISS methodology* yielded a mean probability of survival (Ps) of 0.835. However, the actual survival (AS) rate in this group was 55%. These values were also similar in the damage control group with a mean RTS of 6.11, an ISS of 24.7, and a Ps of 0.781. The AS in the damage control group was 58% (Table 1). Although the demo- sraphics and survival were similar, the damage control approach evolved in the latter part of the study period, with a majority of these cases occurring in the final 2 years of the series. Resuscitation Phase. The mean systolic blood pres- sure on admission to the trauma admitting area (TAA- BP) for definitive laparotomy patients was 97 mm Hg. After an average resuscitation time (TAA-Time) of 25 minutes and the administration of a mean of 2.1 L crystalloid (TAA-Cryst) and 1.1 units packed red blood cells (TAA-PRBC), the mean systolic pressure on arrival Table 1 Demographic dats, injury scoring, and survivorship for the

    You might also like