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Damage Control Resuscitation

Craig S. Cook, MD
President, Utah Surgical Associates; Trauma Medical Director, Utah
Valley Regional Medical Center; Provo, Utah
Objectives:
Examine the historical context of damage control in trauma
surgery and the US Navy
Discuss the specific elements of a damage control laparotomy
Describe techniques for the maintenance and closure of the
open abdomen

Damage Control
Resuscitation
Craig Cook, MD
UVRMC Trauma Medical
Director

Damage Control Resuscitation is


The active conscious process to restore and/or
maintain blood volume, appropriate
thrombogenesis, and tissue oxygenation
which allows for adequate end organ
perfusion in the bleeding patient.

Damage Control Resuscitation is


NOT
Fancy
Easy or effortless
Individual or unilateral
High volume crystalloid resuscitation
Mucking around with central lines or cut-downs
Long OR times
Complex reconstructive procedures early on
Long transfer times or multiple transfers

Damage Control Resuscitation IS


Early control of hemorrhage
Rapid transport to definitive care
Limited crystalloid infusion
Early and liberal use of blood products in approximation of
whole blood (1:1:1)
Permissive hypotension (excluding TBI/SCI patients)
Judicious and early use of tourniquets, pelvic binders, splints,
compressive dressings/direct pressure
Quick peripheral large bore IV
Focusing on and addressing ABCs using available adjuncts
(FAST, CXR, Pelvic X-ray)

DAMAGE CONTROL
RESUSCITATION PRINCIPLES
1. Permissive hypotension
2. Limit crystalloids
3. Deliver blood components in physiologic ratios
(close to whole blood)
4. Adjuvant therapies:
Damage control surgery
Pelvic binders
Tourniquets
Prevention/treatment of hypothermia
Drugs

Case Review
37 year old female helmeted driver of
motorcycle touring multiple National Parks
that suffered a head-on crash with a car
Obvious right femur deformity
Taken to small, local hospital with multiple
complaints
Numerous plain films of extremities obtained
before patient sent for CT scans

Case Review
20 gauge IV started in her hand
While in CT, the patient developed hypotension; systolics
in the 70s
BP came up with three liters of crystalloid
After CT report generated, transfer arrangements initiated
Nearly 6 hours after the accident, the patient arrived at
closest trauma center
Patient lethargic, clammy, and hypotensive
Had received at least 4 liters of crystalloid prior to arrival
Pelvic binder was placed as part of secondary survey

Case Review
Blood product transfusion initiated through a
second large bore peripheral IV while central
IV access was being established
Dramatic response to pelvic binder and
transfusion of 4 PRBC/4 FFP; patient woke up
and complained of pelvic/leg pain
Remained hemodynamically stable
Femur, then pelvis repaired
Discharged to rehab

Historically
For decades, the trauma mantra has been
two large bore IVs and two liters of
crystalloid bolus
The logic was to try to restore normotension
and peripheral perfusion ASAP

Consequences of bleeding
If someone loses enough blood, their blood
pressure will drop
As it is able, an injured patients body will take
the following steps to protect itself from
further blood loss

Vasospasm

Clot formation; initially quite weak/tenuous

Whats been our first response to a


hypotensive trauma patient?

Two large bore IVs and two liters of crystalloid


bolused as fast as possible

What are the consequences of that


crystalloid bolus?
Blood pressure goes up

Just what we want, right?

Blood vessels get stretched


Potentially popping the clot

New Pre-hospital IV Fluid


Recommendations for Trauma
1. Stop visible bleeding
2. Assess for shock
Signs of shock:
Hypotension (SBP<90)
Loss of radial pulse
Decreased mental status

New Pre-hospital IV Fluid


Recommendations for Trauma
If not in shock:
No IV fluids necessary
Intact radial pulse, SBP 90,

normal mental status


Start saline lock (or extension set

/ TKO fluid)

Rapid transport to Trauma Center/ED


Monitor carefully for shock

New Pre-hospital IV Fluid


Recommendations for Trauma
If in shock:
500 1000 cc crystalloid bolus
Reassess
Repeat bolus if necessary

Goal: increase perfusion, SBP 90


Goal is not normal BP

Rapid transport to Trauma Center/ED

Other Important Considerations


Short scene times (< 10 minutes)
Limited scene interventions
Work in back of ambulance en route
to Trauma Center/ED
Patients with hypotension and head
injuries are particularly challenging
to care for as crystalloids can
potentiate cerebral edema
Note: these are adult
recommendations

PERMISSIVE HYPOTENSION
TRAUMATIC BRAIN INJURY
In patients with traumatic brain injury (TBI), it
is critically important to maintain cerebral
blood flow and cerebral perfusion pressure
Permissive hypotension is currently
contraindicated in the setting of significant
TBI

What about once we get the patient to


the hospital?

Blood product transfusion is administered ASAP


and very well may be life saving in patients
with persistent shock and/or ongoing blood
loss

How are blood products to be utilized in


the resuscitation of the bleeding trauma
patient?

Is the blood on the floor just red


blood cells?
Whole blood consists of red cells, plasma,
platelets, coagulation factors, etc
If all we give back are red blood cells, we are
leaving out some other important
components and are further diluting the
other parts of the circulatory volume

Recipe
So what is the ideal recipe to replace what is
being lost when a patient is bleeding to
death?
The initial studies regarding this question came
from the military (Iraq/Afghanistan)

Recipe
They found that when they transfused whole
blood, or a mix of products with ratios
similar to whole blood, that their morbidity
and mortality rates were substantially
improved
Military blood bank unique; walking blood
bank

Recipe
The most significant benefit was found to be in those
who required large volume transfusion (>10
units, and frequently >40 units of blood); i.e.
massive transfusion
A lesser degree of benefit was found in those who
only required moderate levels of transfusion
The body likes blood!

1:1:1
The terminology of transfusing 1 unit of PRBCs to every 1
unit of FFP to every 1 unit of Platelets has gained wide
acceptance; i.e. 1:1:1
The exact ratio for optimal transfusion of the
exsanguinating patient continues to be debated
What is not debated, is that even severely injured civilian
patients who are massively transfused an
approximation of whole blood have improved
morbidity/mortality
Our goal in the exsanguinating patient is to come as close
as possible to the 1:1:1 ratio while stopping further
blood loss as soon as possible

Evidence for Benefit of Early Blood


Products: Military Combat
Experience
Improved survival and decreased complications

Holcomb J Trauma 2003;54(5 Suppl):46

Improved survival and decreased multi-organ failure

Holcomb, et al Ann Surg 2008;248:447

Evidence for Benefit of Early Blood


Products: Civilian Experience
One civilian study showed an 80% to <30%
mortality decrease with implementation of 1:1:1
massive transfusion
Decreased transfusion requirements

Duchense, et al J Trauma 2009;67:216

Excellent current review of IV fluid resuscitation

McSwain, et al J Trauma 2011;70 (5 Suppl):S2

What is the Massive Transfusion


Protocol (MTP)?
The Massive Transfusion Protocol is an attempt to
streamline the process of getting blood products
into the exsanguinating patient from the blood
bank in an orderly manner and in optimal ratios
The protocol is written such that upon its initiation,
blood products will be prepared, delivered, and
transfused in a manner consistent with our goal
of 1:1:1

Massive Transfusion Protocol (MTP)


What is the Massive Transfusion Protocol (MTP)?
What triggers the initiation of the MTP at
UVRMC?
What are the related consequences of the MTP?

PRINCIPLES OF DAMAGE CONTROL


SURGERY
H. Stone, 1983 : first described principle
M. Rotondo, 1993: coined the term and
demonstrated outcome advantage
Stage 1: Abbreviated initial procedure
a. control hemorrhage
b. control contamination
c. temporary closure
Stage 2: Continued resuscitation in ICU
a. reverse hypothermia, acidosis,
coagulopathy
Stage 3: Definitive repair and closure return to
OR

TRANEXAMIC ACID (TXA)


Fibrinolysis = normal process by which body
breaks down blood clots
Overactive fibrinolysis is common in trauma
TXA is an anti-fibrinolytic agent which decreases
breakdown of clot and decreases blood loss
Early TXA should be given for any patient
requiring massive transfusion for trauma
related hemorrhage
Mortality benefit as per CRASH 2 trial

Factor VIIa
Expensive
Forms clot-good and bad
No great data supporting its use; certainly no
mortality benefit

DAMAGE CONTROL RESUSCITATION:


Additional Principles
Not intended for all patients; just the severely
injured
Is a continuum from pre-hospital to definitive
care

Scene Transport ER ICU OR

Early identification of those requiring DCR is


imperative
Over-resuscitation can be nearly as harmful as
under-resuscitation

DAMAGE CONTROL
RESUSCITATION IN REVIEW
1. Permissive hypotension
2. Limit crystalloids
3. Deliver blood components in physiologic ratios (close to
whole blood)
4. Adjuvant therapies:
Damage control surgery
Pelvic binders
Tourniquets
Prevention/treatment of hypothermia
Drugs

UVRMC Trauma APCs


Adam Phillips, PA-C

Tom Asturias, PA-C

UVRMC Trauma APCs


Lindsey Anderson,

NP

Julie Larsen, NP

UVRMC Trauma APCs

Liz Marble, NP