DAMAGE CONTROL

Indicators of pancreatic duct injury

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How will you resussitate the patient

1. Hypotensive resuscitation • Permissive hypotension • Aim to perfuse tissues but not dislodge the haemostatic clot(s) in the absence of brain injury, permissive hypotension (80mmhg systolic, conscious, palpable pulse) UO > .5, is reasonable til haemorrhage controlled 2. Haemostatic resuscitation • 1:1:1 (RBC:FFP:PLT) head, blast and kids exempt

Can Lacerations be sutured

Controversial : hepatorrhaphy is not universally accepted for the fear of hepatic necrosis, if considered . Deep bites with horizontal mattress sutures, usuallywith 0-0 chromic catgut on a large blunt-tipped needle, may effectively control bleeding. The sutures must be placed on healthy liver tissue away from the edges of the wound to avoid tearing through the wound and producing more bleeding

retroperitoneum

Identify which zone. leave the hematoma undisturbed and seek control by postoperative angiographic embolization can try pack, fibrin glue etc. mixed results peritoneum is not opened, so the retroperitoneal space does not become continuous with the intraperitoneal cavity.

what are the 5 phases of management

Immediate goals • Phase 1 = Recognition of appropriate patients • Phase 2 = Control of surgical bleeding, contain GI soilage, temporary abdominal closure • Later goals • Phase 3 = Correct physiology • Phase 4 = Definitive surgery • Phase 5 = Abdominal closure

Other factors

In the elusive quest for the correct balance between performing a lifesaving but imperfect procedure versus a definitive but unnecessarily prolonged operation, experience and team preparedness counts more than absolute numbers

should you create a stoma in DCS

No time consuming stoma net to open abdomen

what are the common sites for missed injury

OGJ, ligament of trietz, mesentry of small bowel , posterior wall of transverse colon,extraperitoneal rectum

second manoveur

controlling contamination. Hollow visceral perforations can be temporarily controlled by atraumatic clamps (e.g., Babcock) or rapid suturing with any type of suture material already available on the table

Why has excessive crystalloid ressuscitation been replace

disrupts soft thrombus as pressure rises in vessel - cardiac output increases causes coagulopathy and anaemia - dilutional trauma is a haemodynamic and an immune disease IL-6 higher in nonsurviors, IL-1, 10 TNFa also implicated fluids and drugs affect both increased neutrophil oxidative burst with LR, isotonic crystalloids

Heart

emergency room skin staples sutures control atria by manual compresion in desperate situation and resart with compressions or defibrillator

what are the 3 general phases of DCS

first phase, an abbreviated operation aims to control bleeding and contamination by rapid surgical maneuvers, including packing, vessel ligation, vessel shunting,bowel resection without anastomosis, and open abdomen. "better is the enemy of good." second phase, the patient is transferred to the ICU for aggressive resuscitation, rewarming, and correction of coagulopathy. third phase includes return to the operating room to definitively repair the injuries by reconstituting vascular and bowel continuity,completing the resection of injured organs, unpacking, and closing the abdomen. This third phase may require more than one

What fluid would you use for resusitation

hypertonic saline rapid expansion of plasma volume after blood loss 250ml @ 7.5% = 3L @ 0.9% used initially as a volume expander, now as an immunomodulator no change to rates of hypernatremic sz, coagulopathy, transfusion, arrhythmia, renal failure, central pontine demyelinosis decreases neutrophil excitation, inflam, binding, lung and bowel injury hartmanns if more required

Pancreas

proximal injuries always pack and drain distal to smv may consider distal pancreatectomy in experienced hands especiall if duct transectedbut more likely on return to theatre.

Damage control Laparotomy first manoeuvre

rapid evacuation of blood and blood clots, gross identification of the location responsible for the bleeding,and targeted packing of that area. or 4 quadrant packing ,control bleeding with soft clamps or fingers

Re‐operation principles

removal of clots and packs􀃒 complete inspection to detect missed injuries􀃒 restoration of intestinal integrity or stoma abdominal wound closure

small bowel techniques

• Direct surgical repair, sutured transverse closure of simple perforations • Resect if multiple perforations in small confined segment • Or combination of above measures • Stapled resection (quick and easy) without anastamosis • Must inspect whole small bowel, both sides, don't miss injury to mesenteric side

What veins can be ligated ?

Most veins in the abdomen—except the suprarenal inferior vena cava, portal vein, and superior mesenteric vein—can be safely ligated. Ligation of the splenic vein may need a splenectomy, and ligation of the renal vein may also need a nephrectomy, if it is not close to the inferior vena cava. Ligation of the infrarenal inferior vena cava is usually well tolerated, although temporary edema is common, and extremity fasciotomies may be required on occasion. The same is true with ligation of the common and external iliac veins.

Haemstatic resussitation

'early use of blood and products to prevent dilutional coag through treatment with products as they are replaced' 1:1:1 if projected for MT, the only debate now is 1:1:2! fibrinogen if <1.5g/l with cryo consider VIIa @ 100mcg/kg

Kidney

A patient who needs an abbreviated laparotomy because of multiple injuries is better served by a nephrectomy. If this decision is made, the contralateral kidney should be palpated to assess its location and size. Renal function tests are unnecessary, as it is extremely unlikely that a normal-size, normal-site kidney is not functional.

How does acidosis develop

Acidosis is a result of hypoperfusion Often worsened by excessive normal saline • Increased lactate secondary to anaerobic metabolism • Action • Inhibits activity of enzyme complexes on lipid surfaces • Impairs clot formation and reduces clot strength, independently prolongs APTT • Reduces cardiac contractility, can cause arrhythmias • Attenuates response to inotropes

Damage Control Angiographic Embolization

Angiographic embolization has become an indispensable method of controlling pelvic and other organ bleeding involve the main stems of both internal iliac arteries by injecting gelatin sponge particles Subselective embolization by coils is time consuming and likely to fail, as it is rare that only one site is responsible for life-threatening bleeding from a major pelvic fracture; usually, it is the entire pelvic vascular plexus that bleeds.

Open abdomen techniques

Bogota bag Vac pac review every 48 hours closure as possible from bottom and top biologic mesh closure

what vesels are embolised in DC . what are the complications

By embolizing both internal iliac arteries with a temporary agent, the blood pressure in the pelvic vessels decreases, allowing clotting to occur. The procedure takes only a few minutes. Usually, there is still sufficient blood supply to ensure organ viability; in some case reports, gluteal muscle necrosis or rectal sloughing has been observed, it is very rare that significant complications occur The vessels typically recanalize within 5 to 14 days after embolization, 15% of patients subjected to embolization may rebleed and require reembolization.

DC orthopaedics

Damage control orthopedics aim to stabilize the bone effectively while avoiding a major secondary inflammatory insult. Operative repairs on fractures that can be otherwise stabilized (e.g., splints, traction) should be delayed until the completion of resuscitation. Following that, external fixation is advisable over

What are the physiologic criteria

Decline in physiologic reserve T < 35 pH < 7.2 lactate > 5, base defecit >14 PTT > 60 10u PRBC estimated blood loss .4 litres sBP < 90 for > 60 min Operating time > 60 min

What equipment will youhave ready

Fixed retractors • Packs (x30) opened • Sutures • Staplers • Suckers x 2 • Cell saver • Fluid warmers • Rapid infuser • Head ligh

goals of temporary abdominal closure

Goals:􀃒 Containment of viscera Control of ascites Prevention of compartment syndrome Maintenance of tamponade in areas of packing Optimization of later fascial closure

Physiology . what is the deadly triad?

HAC Hyothermia Acidosis Coagulopathy

What about trauma laparoscopy?

Incidence of unnecessary laparotomies for trauma varies 2‐38% and depends on unit experience and policies. Morbidity directly related to this can be as high as 25% Use of laparoscopy has been associated with a small decrease in incidence of negative and non‐therapeutic laparotomy 􀃒Not considered frontline method for evaluation but is an important adjunct Useful in penetrating injuries to visualize peritoneal breech ordiaphragmatic injury* Difficult to assess retroperitoneal structures and bowel Not accepted for blunt trauma It is not a substitute for open procedure, especially in the presence of haemoperitoneum or contamination or pt with haemodynamic instability or obvious complex intra‐abdominal injury

duodenal injury

Kocherise duodenum to inspect adequately Duodenal perforations occupying less than 50% of the lumen's circumference can be closed primarily. A case-by-case decision must be made for larger perforations; some can still be closed primarily, whereas others need a more complex procedure, such as a serosal (Thal) patch, duodenojejunostomy, or pyloric exclusion. Closure of the duodenal perforation around a large-bore drainage tube is another temporary alternative.

Diapghmn

L > R, usually posterolateral􀃒 Most commonly 5‐10cm in length Irrigate pleural cavity well via defect if abdominal contamination present Primary closure with interrupted non absorbable sutures Leave tied sutures long so you can get retraction of muscle for next stitch

What if there is a large retrohepatic haematoma

Large retrohepatic hematomas are best left unexplored if not bleeding dramatically. Uncovering a retrohepatic inferior vena cava or major hepatic vein injury is associated with a mortality of 60% to 90%. There is little reason to risk a fatal outcome by opening the hematoma, if it can be left alone or controlled by packing. If direct damage to:􀂏 Hepatic artery 􀃎can ligate Hepatic vein 􀃎need to repair Biliary tree 􀃎T‐tube and drains

How does hypothermia develop?

Lying on the ground at the trauma scene, particularly in cold weather or in wet clothes, being unclothed in the emergency room, having viscera exposed in the operating room, transfusion of cold fluids and blood products, vasoconstriction due to blood loss, use of vasopressors all contribute to hypothermia. Increased pooling of platelets in the spleen • Decreased platelet activation • Inhibiting vWF - platelet glycoprotein complex • Slowed rate of coagulation factor enzymes • Inhibition of fibrinogen synthesis • Cardiac arrhythmias when very cold (<32℃)

What are the tips fpr liver packing

May need to improve exposure by mobilising liver • Falciform, triangular ligaments • Compress liver edges together • Don't pack into liver lacerations • Pringle manoeuvre • avoiding compression of the inferior vena cava. Communication with the anesthesiologist is important during placement of the packs to ensure that cardiac preload is still adequate. If the hemodynamics deteriorate rather than improve after pack placement, the packing must be rearranged, as the cava may be compressed.

What are the criteria to interupt the progress of the lethal triad with DCS

Ongoing bleeding (but abort before coagulopathic!) Clinical evidence of coagulopathy (nonsurgical bleeding) Combined vascular, solid + hollow-organ injury Inaccessible major venous injury Need for a time-consuming procedure Non-surgical requirement eg pelvic fracture Associated life-threatening injuries in a second anatomic location Vascular injuries in inaccessible locations Inability to close the abdomen due to visceral edema or relook required

Indications for liver packing

Packing used in 3 main circumstances 1. Temporary measure to allow resus and treatment of other injuries 2. Definitive treatment of complex hepatic injuries beyond surgeon's ability 3. Deadly triad with diffuse bleeding ➔ packing is only solution in this settin

situational indicators

Penetrating thoraco-abdominal injury with severe shock • High energy blunt trauma • Victims of primary blast injury • Two proximal amputations • Major vascular injury with major visceral injury • Severe multi-body cavity injury • Other life threatening injuries in other anatomic location • Mass casualties

Phase 1

Preparation - Phase 1 • Heat theatre to 27-29℃ • Warm all fluids and blood products • Bair hugger • Early notification of theatre staff & anaesthetics (& radiology) • Anticipation of major blood loss - early activation of MTP • Central and arterial access (timing) NG tube, IDC & preoperative antibiotics • Avoid over-resuscitation before haemorrhage control obtained • Permissive hypotension

stomach

Quick surgical repair with sutured closure • Enter lesser sac via gastrocolic omentum • Inspect posterior wall, esp in penetrating trauma therfore have to enter leser sac

Prinicple of damage control

RAPID . EFFECTIVE . TEMPORARY. Overarching goal is haemorrhage and contamination control Minimise operative time and stress before physiologic exhaustion Requires enough intervention to limit further SIRS/organ dysfunction Staged laparotomies • Deliberately abbreviated laparotomy • Temporising measure to salvage otherwise moribund trauma patients • Applicable to exsanguinating trauma patient when surgical bleeding controlled and ongoing blood loss due to hypothermia and coagulopathy • Physiological exhaustion manifest by hypothermia, acidosis and coagulopathy "Deadly Triad" • Aim is to break the pathophysiological cycle

Small bowel

Run the whole bowel prior to any resection Most small bowel and colon perforations should also be closed primarily. If a resection is necessary, it should be performed with staplers to minimize operative time. Depending on the urgency to "bail out," an anastomosis could be performed, or the resected ends could be left in the abdomen until bowel continuity is restored at a second operation. " resect and drop "staplers for the resection, hand sew the anastomotic line in one layer with two running absorbable sutures going in opposite directions

what temporasing procedure can be done for arteries

Shunting is an effective temporary way to maintain blood supply distal to the injury without ligation. A variety of shunts have been used for this purpose, an Inahara-Pruitt shunt or a simple carotid shunt. A piece of a nasogastric tube could be equally effective, if a shunt is not readily available. can be left for up to 4 days

Spleen

Splenectomy • Rapid mobilisation of splenic attachments • splenophrenic, splenorenal, short gastrics • Mobilise to midline • Packing if minor injury , unlikely but could consider • Mesh wrap • Partial splenectomy • Splenorrhaphy

What arteries?

Splenic, hepatic, left gastric, and renal arteries can also be ligated, but others should not, such as the aorta and superior mesenteric artery. Successful ligation of the iliac arteries has been reported, but we do not recommend it.

lung

Upon entering the chest, severe bleeding from the lung can be controlled by clamping the hilum. The inferior pulmonary ligament should be cut, and a Satinsky clamp should be placed around the hilum. Another technique to achieve the same result is twisting of the lung by 180 degrees, which occludes the inflow and outflow but makes the anatomical identification and exploration of injuries more awkward.

Damage Control Thoracotomy

The patient should be placed supine with a pillow under the involved hemithorax. An anterolateral rather than posterolateral thoracotomy should be used, and time should not be spent to perform and confirm a double-lumen endotracheal intubation; a straightforward, single-lumen intubation is preferable, and a bronchial blocker can be used to exclude one lung if needed

third manoveur

The third move consists of unpacking the area and assessing thebleeding site. start with least likely bleeding site. A rapid determination needs to be made about the potential of definitive repair or temporary control, and it is exactly at this point that an early decision must be made about abbreviating the operation based on the extent of the injuries and physiology of the patient.

Damage Control Thoracotomy

infrequent, as the two most commonly used elements of damage control, packing and leaving the cavity open, are harder to apply in the chest. The focus is on rapid bleeding control without extensive surgical maneuvers

How does coagulopaty develop

is a result of hemodilution resulting from the infusion of acellular fluids and aged blood products, consumption of coagulation factors during the inflammatory process, secretion of fibrinolytic agents. Direct loss of factors secondary to haemorrhage ➪ reduced stores of fibrinogen and platelets Independent indicator of mortality

ICU

once in ICU keep BE and lactate trending down to normal over 24 hrs rather than rapid correction

lung parenchymal injury

parenchymal, a stapled tractotomy is the fastest way to open the tract and individually ligate bleeding vessels. A gastrointestinal anastomotic stapler is applied through the bullet trajectory and fired. The tract then opens, and bleeding sites can be controlled by sutures. A stapled pulmonary resection can be safely done, whether it is the lobe or the entire lung that needs removal. A thoracoabdominal stapler is applied at the hilar structures en masse and fired

Vascular and Orthopaedic trauma

unique challenge. Delaying vascular restoration until the bone is fixed prolongs ischemia to the distal extremity. Repairing the vessel before orthopedic fixation subjects a tenuous anastomotic line to major manipulation temporary shunting is the solution. The first step is to identify the vessel and insert a shunt to provide distal blood supply. The second step consists of the orthopedic repair. Finally, the operation is completed on the third step, which includes the removal of the shunt and definitive repair by primary vascular repair or with the use of a native or artificial graft

describe the general principles of DCS nephrectomy

usually preferable to control the hilar vessels before opening the Gerota fascia, in cases of damage control,can open the fascia first, deliver the kidney rapidly to the field while manually compressing it, and apply clamps to the hilum and ureter last. Nephrectomy by this maneuver should not take more than a few minutes. In cases of ureteral but not renal injury, a tube is inserted in the ureter and exteriorized through the skin as a ureterostomy.

Organ specific maneuvers LIVER

• Push • Apply pressure • Pack • Reconstitute as best as possible to normal shape and position • Mould around liver with direct compression • 4-6 packs, cover in plastic sheet/ Ioban to avoid clot disruption on removal • Pringle • Open hepatoduodenal ligament and compress portal triad • Digital pressure, soft bowel clamp, vascular clamp, sling • Plug • Sengstaken-Blakemore tube, penrose on Foley's for gunshot type injuries • Omentum

Phase 2

• Should aim to limit total theatre time to <1hr (where possible) • Control bleeding • Limit contamination • Temporary abdominal closure prep and drape prior to induction if possible neck to knees and one leg for veins • Long midline incision may have to open chest midline or laterally • Eviscerate the small bowel expect haemodynamic changes after incision and paralysis and release of bleeding • Avoid use of suction (manually remove blood & clots) • Rapid 3 (4) quadrant packing for haemorrhage control RUQ, LUQ, pelvis • If bleeding persists • Second round of packing inserted • Definitive measures to control • Splenectomy, nephrectomy, liver packing, vascular contro