Damage Control Surgery Flashcards
(10 cards)
What is Damage Control Surgery?
DEFINITION
- The rapid initial control of hemorrhage & contamination, temporary abdominal closure, resuscitation to normal physiology in ICU followed by subsequent re-exploration & definitive repair.
What are the aim of damage control surgery?
- Restore normal physiology (hemostasis & contamination control) rather than anatomy (Defer treatment of anatomical disruptions)
- Prevent lethal triad
What are the phases of damage control surgery?
-Phase 1 : Identify
-Phase 2: Primary DCS
-Phase 3: critical care
-Phase 4: planned reoperation
-Phase 5: Definite Abdominal wall closure
Describe Phase 1 ( Identify) of DCS
PHASE 1 (IDENTIFY)
- Preoperative indication
• Multiple life threatening injuries.
• Combined hollow viscus & vascular or solid
organ injury.
• Presence of lethal triad.
- Intraoperative parameters for initiation of DCS
• Hypothermia ≤ 34 degree Celcius
• Acidosis pH ≤ 7.2
• Serum bicarbonate ≤ 15 mEq/L
• Clinical evidence of coagulopathy
• Transfusion of ≥ 4L blood
• Transfusion of ≥ 5L blood & blood products
• Intraoperative volume replacement ≥ 12L
- Decision for DCS should be made early. The earlier the better the outcome.
Describe Phase 2 ( Primary DCS) of DCS
PHASE 2 (Primary DCS) - Limit to 60-90min
First priority : Hemorrhage control
Second Priority: Control Contamination
1) Control of Hemorrhage
* Aim to control hemorrhage not maintenance of blood flow.
* Hemorrhage control
- Vessel : Ligation, shunting
- Solid organ : Excision, packing, balloon catheter tamponade
2) Exploration to determine extent of injury
* Perform only essential resection or packing.
* No definitive reconstruction.
* Assessment & stabilization of major extremity & pelvic fractures
3) Control contamination
* Intestine is inspected from the ligament of Treitz to the rectum
* Small enterotomy : Primary closure
* Non viable bowels : Resection without anastomosis. Can resect up to 50% bowel length ( Chop &drop / stoma)
* Extent of bowel wall injury is often not apparent at the initial operation; delayed bowel ischaemia- bowel viability is always re-assessed later
* Biliary and pancreatic ductal injuries can be managed initially by simple drainage to form controlled fistula
4) Temporary packing
* Tamponade liver, pelvic & retroperitoneal bleeding with large abdominal packs.
* Principles of packing:
- Pressure stops bleeding
- Pressure vectors should re-create tissue planes (attempt to re-create pressure vectors by the capsule of a solid organ, not random packing)
- 4 quadrant packing ( <5 min)
- if still hypotensive after packing, a significant arterial hemorrhage is likely: Control of aortic inflow with manula occlusion of the aorta at the diaphragmatic hiatus can be performed quickly and give anaesthtic tesm some time to catch up with volume replacement
- by the time, the bleeding would have stop
- Then the packs are then removed, beginning in the quadrant farthest away from the greatest amount of hemorrhage
- Ongoing non surgical bleeding - the packs are replaced and may be left in the abdomen
If Surgical bleeding:
- Controlled with suture
- Large liver lacerations - torrential bleed, best managed by packing / surgel & pack / pringle
- High grade splenic injuries - splenectomy is the procedure of choice for DC
Vascular injury:
- Vascular shunts/ ligation
Uro:
- Most bladder injury: repaired primarily and then drained with a Foley Catheter
- Larger bladder defects- packing , and acatheter drainage and recontruct later
- Utereteric injury can repaired primarily over a stent
- in unstable patient, can simply be drained to the abdominal wall ( with feeding tube into the proximal lumen) OR even tied off and NT later if patient survived
Principles of Temporary abdominal closure:
- Must have non adherent layer on top of bowel & tuck under peritoneum as far lateral as possible.
-Perforate the layer to allow fluid to drain out
-Adequate drainage tube between gauze or foam & brought out through top of wound with low pressure suction.
-Water tight seal to skin with opsite or tegaderm.
-Do not sew fascia
-Adequate sedation.
* Choices : Bogota bag, vacuum pack, wound VAC
What is Phase 3 ( Critical care) of DCS
PHASE 3 (Critical Care)
- Restoration of normal physiology in 24-48 hours
include:
• Core rewarming
• Reversal of acidosis
• Reversal of coagulopathy
• Ventilatory support
• Identification of occult injury
• Monitor for ACS (Abdominal compartment syndrome)
- Aim:
• Acidosis: : Lactate < 2.5, BE < - 4
• Temperature: : > 35 degree celcius in 4 hours
• Coagulopathy: : Hb > 7, Plt > 100, Fibrinogen < 100mg/dL , INR < 1.2
What is Phase 4 ( Planned reoperation) of DCS?
PHASE 4 (Planned Reoperation)
- Timing is usually 24 – 48 hours after trauma unless
patient develop ACS, peritonitis or bleeding.
- Aim:
• Definitive organ repair
• Complete fascia closure
- Re-operation include:
• Complete removal of abdominal packs (48 – 72H)
• Complete re-exploration of all injuries.
• Primary repair with end to end anastomosis.
• Consider repacking if other measure fail to control hemorrhage.
• Copious washout performed
What is PHASE 5 (Definite Abdominal Wall Closure) of DCS?
PHASE 5 (Definite Abdominal Wall Closure)
- Abdominal wall closure
• Primary mass closure with loop nylon
• Temporary closure with VAC dressing can aid in tissue granulation & plan for abdominal wall reconstruction later (component separation technique)
What are the complication of DCS?
COMPLICATIONS
- Abdominal compartment syndrome
- Wound complication : dehiscence, sepsis, fistula - General complication: CVS, RESP, RENAL
Damage Control Resuscitation (DCR)
🔑 Core Principles
Goal: Achieve survivable physiology before definitive surgery.
Combines:
- Permissive hypotension
- Haemostatic (blood-based) resuscitation ( DCR is about aiding blood recovery, using a holistic approach to replace the functionality of whole blood)
🚑 1. Permissive Hypotension
Maintain lower BP to minimize bleeding until haemostasis.
Target SBP ~90–100 mmHg (higher in TBI patients).
Limit duration to 60 mins (hybrid approach) to prevent hypoperfusion and acidosis.
The use of permissive hypotension
is a balancing act, with haemorrhage and under-perfusion the vital organs that both result in significant physiological insult.
🩸 2. Haemostatic Resuscitation
Use blood products early (preferred over crystalloids).
Follow 1:1:1 ratio of RBCs : Plasma : Platelets.
Avoid large-volume crystalloids → worsen:
Coagulopathy
Acidosis
Hypothermia
🧪 3. Monitoring & Testing
Use Point-of-Care Coagulation Testing (POCCT)(viscoelastic haemostatic assay (VHA)) like:
- TEG (Thromboelastography)
- ROTEM (Rotational Thromboelastometry)
Helps tailor transfusion strategies and reduce unnecessary blood use.
💉 4. Key Therapeutics in DCR
Fibrinogen replacement (target >1.5 g/L)
Platelets and FFP
Calcium replacement (to counter citrate binding from transfusions)
Tranexamic Acid (TXA): within 3 hours of injury (per CRASH-2 and CRASH-3 trials)
❄️ 5. Hypothermia Prevention
Use warm IV fluids, warming blankets, body lavage if needed.
Maintain temperature >35°C to preserve coagulation.
⚖️ Overall Strategy
DCR is a temporary, physiology-first approach.
Enables:
Safer surgery (DCS)
Better survival outcomes
Must be individualized and adjusted based on:
Patient response
Lab markers
Ongoing bleeding assessment
