Current Concepts of

Damage Control Resuscitation and Damage

Control Surgery

The Definitive Surgical Trauma Care

The College of Surgeons of Indonesia
2019
 Objectives :

● Discuss the pathophysiology of triads of death

● Summarize the current concept of Damage
Control Resuscitation (DCR)
● Discuss the recent updates on Damage Control
Surgery (DCS)
● Discuss the strategy in implementing DCR and
DCS
 Backgrounds

● Most preventable in-hospital deaths from trauma are due to

uncontrolled hemorrhage and resultant coagulopathy

Evans JA, van Wessem KJ, McDougall D et al: World J Surg 2010; 34(1) :158-163

● To increase the chances of survival:

❖ surgically control hemorrhage,

❖ successfully resuscitate the bleeding patient,
❖ adequately correct traumatic coagulopathy
 Problems in Hemorrhagic Shock
Coagulopathy

Acidosis

Severe trauma Bleeding Tissue

hypoxia

Hypothermia

Colloid and Dilution of

Crystalloid infusion Coagulation factors
And platelets

Massive RBC
transfusion
Moore EE : Am J Surg 172: 405-410 1996
 Traumatic Coagulopathy

Mc Leod, JBA, Arch Surg 143, Aug.2008

The Trauma Team: How to implement?
 Historical Backgrounds of DCS

● Some very seriously injured patients when subjected to a

decisive surgery completed in one setting finally
succumbed either in the operating table or shortly after in
the ICU.
● 1980s : Stones et al used perihepatic packing + TACD
● 1992 : Burch et al : Triad of Deaths + abbreviated
Laparotomy in 200 cases.
● 1993 : Rotondo et al : Damage Control Stages
(DC1,DC2,DC3)
● 2001-2011: DC0 (DCR) and DC4 (Reconstructive)
Damage Control in the US Navy
Damage Control Surgery
DAMAGE CONTROL
RESUSCITATION
 Current Definition of
Damage Control Resuscitation:

● a systematic approach to the management of the trauma

patient with severe injuries that starts in the emergency
room and continues through the operating room and the
intensive care unit (ICU).

● It is designed, along with damage control surgery, to

promptly and aggressively reverse the lethal trauma triad
of coagulopathy, acidosis, and hypothermia.
 Combination DCS + DCR

● improve 30-day patient survival

● Five pillars of DCR:

(1) body rewarming,
(2) correction of acidosis,
(3) permissive hypotension,
(4) restrictive fluid administration, and
(5) hemostatic resuscitation.
Damage Control Resuscitation and
Surgery Algorithm

H.M. A. Kaafarani, G. C. Velmahos

Scandinavian Journal of Surgery 0: 1–8, 2014
 Pre hospital Care

Scoop and Run Injury

Minimize Fluid Resuscitation

Prevent Hypothermia

GOAL:
Pre Hospital Care
Get the patient to the trauma Less than 20 minutes
center
 Resuscitation

Allow permissive hypotension

Administer blood and blood

products early

Minimize fluid resuscitation

Start Tranexamic Acid

Start massive transfusion protocol

Emergency Room
GOAL: Less than 30 minutes

Mobilize promptly to OR/IR

Suite
 Operating Theater

Allow permissive hypotension

Aim for 1:1:1 PRBC/FFP/Platelets

ratio

Administer cryoprecipitate

Abdominal packing

Temporary abdominal closure

Abbreviated surgical
GOAL: Procedure

Control surgical bleeding Less than 90 minutes

Control contamination
 Intensive Care (1)

Reverse hypothermia

Reverse coagulopathy

Reverse acidosis

Support hemodynamics

GOAL:
Intensive Care Unit
Resuscitate 12 – 36 hours
Reverse Triads of death
 Operating Theater

Remove packing

Definitive Surgical Repair

Serial primary abdominal closure

GOAL: Definitive surgical

procedure
Definitive Surgical Repair (2 – 8 days)
 Intensive Care (2)

Diuresis

GOAL:

Decrease fluid overload to

allow:
1. Definitive abdominal closure
2. Postoperative liberation from
ventilator Intensive Care Unit Stay
(2 – 8 days)
 Reversing Hypothermia

 Body Rewarming:

 (1) passive external rewarming (e.g. removal of wet

clothing, warm blankets, raising the ambient
temperature of room),
 (2) active external rewarming (e.g. forced air-warming
devices),
 (3) active internal core rewarming
 Reversing Acidosis
 It
is better achieved through:
 aggressive blood and blood product resuscitation
 vasopressor support until surgical control of hemorrhage is
achieved, shock is reversed, and end-organ perfusion is
restored.

 End-points of resuscitation:
 Vital signs alone are poor indicators of end-organ perfusion.
 Base deficit and lactate levels are reliable perfusion indices
(markers of the adequacy of resuscitation);
 Permissive Hypotension

Definition:

A strategic decision to delay the initiation of fluid

resuscitation and limit the volume of resuscitation
fluids/blood products administered to the bleeding
trauma patient by targeting a lower than normal blood
pressure, usually a SBP of 80–90 mmHg or MAP of 50
mmHg.
 Restrictive Fluid Administration

 intravenous fluids should be minimized.

 Aggressive fluid resuscitation results:

 in worse coagulopathy,
 an exaggerated trauma-related systemic inflammatory
response syndrome (SIRS),
 an increased incidence of adult respiratory distress
syndrome (ARDS), pulmonary edema, compartment
syndrome, anemia, thrombocytopenia, pneumonia,
electrolyte disturbances, and overall worse survival
 Hemostatic Resuscitation

 One of the main pillars of DCR is early and

aggressive transfusion of blood products aiming
for a ratio of PRBCs, FFP, and platelets that
approximates 1:1:1

 Massive transfusion is typically defined as a

transfusion of 10 or more units of PRBCs within
the first 24 h of injury
 Role of Hemostatic Adjuncts

 These agents may:

 decrease mortality,
 transfusion requirements,
 rates of transfusion-related organ failure among
certain trauma patients.

 BUT, increase thromboembolic events

 Hemostatic Adjuncts

 Tranexamic acid:
 Prevent fibrinolysis
 Useful within 3 hours of injury
 Recombinant human factor VIIa:
 Does not decrease mortality
  thrombo-embolic complications
 Prothrombin complex, which contains factors II, VII, IX,
X, C,and S:
  mortality,  transfusion requirements, 
complications, &  lengths of stay
 Hemostatic Adjuncts

 Anti-fibrinolytic agents
 Early administration of tranexamic acid (TXA), an
anti-fibrinolytic agent, (slightly decrease the risk of
death from bleeding)

 Factor-concentrates
 recombinant factor VIIa or prothrombin complex
concentrates (PCCs) (lack of evidence)
 Resuscitation Goals and Monitoring

● Coagulation test is inappropiate opiate

● PRBCs should be given to target a hemoglobin >7 g/dL,
● FFPs to target an international normalized ratio (INR) <2,
● Platelets to target a count >50,000,
● Cryoprecipitate to target a fibrinogen level >100 mg/dL.
● The use of thrombo-elastography-based protocols
(promising results)
 DAMAGE CONTROL SURGERY
FOR ABDOMINAL TRAUMA

Laura Godat, Leslie Kobayashi, Todd Costantini and

Raul Coimbra
World Journal of Emergency Surgery 2013, 8:53
 The Indications: Pre operative

● The decision should be made early (pre operative):

❖ Systolic blood pressure (SBP) <90 mmHg with
penetrating torso,
❖ Blunt abdominal, or severe pelvic trauma,
❖ The need for resuscitative thoracotomy
❖ Other Emergency Department (ED) variables :
➢ include SBP <60 mmHg,
➢ hypothermia,
➢ inappropriate bradycardia,
➢ pH of <7.2
Indications
 Considerations

1. The patient’s physiology and trauma burden

2. The experience of the surgeon and the capabilities

of the surgical team.

3. Logistical factors ( the hospital capacity and

availability of a tertiary or quaternary referral)
 The Indications: Intra-operative

● “ non-surgical” bleeding,
● pH≤ 7.18,
● temperature ≤ 33°C,
● transfusion of ≥ 10 units of blood,
● total fluid replacement >12 L,
● estimated blood losses of ≥ 5 L
● Platelet count, PT, aPTT, fibrinogen levels and
thrombo-elastography findings
 Damage Control Laparotomy

● Obtaining control of hemorrhage

● Limiting peritoneal contamination
● Applying temporary abdominal closure.
Damage Control Laparotomy
Damage Control Laparotomy
 The Indications for Open Abdomen:
Intra-operative

● Patients at high riskfor ACS should be left open

prophylactically at the time of laparotomy:

❖ Patients requiring large volume resuscitation (>15 L

or 10 Units of PRBCs),
❖ Those with evidence of visceral edema,
❖ peak inspiratory pressures >40,
❖ intra-abdominal pressure (IAP) >21 during attempted
closure [12-16].
 The perioperative Critical Care

● sedation,
● paralysis,
● nutrition, started early
● fluid management strategies may improve closure
rates and recovery.
● Prophylactic antibiotics no more than 24 hours.
● Reconstructive strategies that may be used in the
acute and chronic phases of abdominal closure (6 -
12 months).
 Temporary Abdominal Closure Devices

● Negative pressure dressing such as the “ vacuum

pack” method or its commercially available
alternative.

● After 5-7 days if the abdomen cannot be closed

convert to the use of a bridging device which
progressively brings the fascia together such as
the Wittman patch or modified V.A.C.©.
VACUUM OPEN ABDOMEN MANAGEMENT
Comparison the results of various techniques
 Damage Control Thoracotomy

● Releasing cardiac tamponade

● Compressing the proximal aorta
● Packing the chest cavity for general hemorrhage control.
Damage Control in Vascular Trauma
 Complications of DCS
● wound complications is as high as 25%.
● intra-abdominal abscesses
● Enteroatmospheric fistulae:
➢ Prolonged exposure of viscera
➢ Frequent dressing changes
➢ Type of prosthetic placed
➢ Fascial dehiscence.

● Ventral Hernia
 Complications of DCS

● Thoracic damage control:

❖ infections and wound complications.
❖ retained hemothorax, prolonged air leaks, bronchopleural
fistulae, and spit fistulae

● Vascular damage control:

❖ distal ischemia from either ligation or subsequent
thrombosis of the injured vessel, venous hypertension,
infection, and limb loss.
❖ Shunt occlusion (5%)
 SUMMARY

● The successful resuscitation of the massively bleeding and

unstable trauma patient will depend on:

➢ effective trauma team leadership,

➢ identification of early trauma-related coagulopathy,
➢ sound decision-making in the emergency and
operating rooms
➢ prompt implementation of a DCR and a damage
control surgery.
 SUMMARY

● Damage control surgery:

❖ a concept that promotes unconventional surgical techniques
that restore normal anatomy and physiology over several
staged procedures.
❖ Avoidance of physiologic derangement by abbreviating the
index surgical procedure, including hemorrhage and soiled
control.
● Recent concepts in DCS:
❖ Identification patients at risk
❖ novel methods of hemorrhage control and injury management,
temporary closure to the chest, & vascular shunts.
thank you