Trauma - Damage control surgery

Question 1

What is the purpose of the damage control laparotomy?

Answer 1

To reverse pre-terminal effects of exsanguination, massive injury, and shock

These maneuvers aim to stabilize unstable patients.

Question 2

What is the goal of minimizing operative time and additional surgical insult?

Answer 2

To reduce the lethal triad: hypothermia, metabolic acidosis, coagulopathy

This is crucial for patient stabilization.

Question 3

What is the lethal triad that needs to be reduced?

Answer 3

• Hypothermia
• Metabolic acidosis
• Coagulopathy

These conditions are critical in managing unstable patients.

Question 4

What is the intended outcome for patients after the surgical intervention?

Answer 4

To stabilize the patient in ICU and return them to theatre for definitive treatment

This process is essential for comprehensive care.

Question 5

What are the 5 stages of damage control laparotomy (including preop and post op)?

Answer 5

Patient selection

Operative technique

ICU post-op Care

Re-look procedures & definitive Repair

Delayed abdominal Closure

Question 6

What two main factors indicate a need for damage control surgery (DCS)?

Answer 6

Bad Physiology AND/OR Bad injury

Question 7

What systolic pressure indicates haemodynamic instability requiring DCS?

Answer 7

Systolic pressure <90mmHg for more than 60min

Question 8

What body temperature indicates metabolic instability for DCS?

Answer 8

Temperature <35

Question 9

What pH level is indicative of metabolic instability requiring DCS?

Answer 9

pH <7.2

Question 10

What base excess level indicates the need for DCS?

Answer 10

Base excess >5

Question 11

What lactate level indicates metabolic instability for DCS?

Answer 11

Lactate >5

Question 12

What prothrombin time (PT) indicates coagulopathy for DCS?

Answer 12

PT >16sec

Question 13

What activated partial thromboplastin time (APTT) indicates coagulopathy for DCS?

Answer 13

APTT >60

Question 14

What type of assay abnormalities indicate coagulopathy that may require DCS?

Answer 14

Abnormal viscoelastic haemostatic assay (TEG)

Question 15

What aspect of surgical anatomy is crucial when considering DCS?

Answer 15

Complex injury requiring complex definitive repair

eg retrohepatic ivc injury

Question 16

What type of venous injury may necessitate DCS?

Answer 16

Inaccessible major venous injury (e.g., retrohepatic vena cava, pelvis)

Question 17

What conditions may lead to the anticipation of time-consuming surgical procedures in DCS?

Answer 17

Suboptimal response to resuscitation, inability to perform repair in timely fashion

Question 18

What logistical blood requirement suggests DCS is necessary?

Answer 18

Blood requirement >10 units

Question 19

What operating time threshold may indicate the need for DCS?

Answer 19

Operating time >60min

Question 20

What situation requires consideration of DCS due to limited resources?

Answer 20

Mass casualty situations

Question 21

What is the first priority in ICU care post-op after damage control surgery?

Answer 21

Restore body temp

Maintaining normothermia is crucial for metabolic processes and recovery.

Question 22

What is the goal for hemoglobin (Hb) levels in ICU care post-op?

Answer 22

Aim Hb 80-100

This range is often targeted to ensure adequate oxygen delivery to tissues.

Question 23

What should be optimized to improve oxygen delivery in ICU care?

Answer 23

Optimise oxygen delivery

This may involve managing ventilation and oxygen supplementation.

Question 24

What must be restored to maintain hemodynamic stability post-operatively?

Answer 24

Restore circulating volume

This is critical to ensure effective perfusion and tissue oxygenation.

Question 25

What metabolic condition should be corrected in ICU care?

Answer 25

Correct acidosis ## Footnote Acidosis can impair cardiac function and oxygen delivery.

Question 26

What type of support may be necessary in ICU care post-op?

Answer 26

Inotropic support as needed ## Footnote Inotropic agents can help improve cardiac contractility and output.

Question 27

What abnormalities should be corrected in ICU care?

Answer 27

Correct clotting abnormalities ## Footnote This is important to prevent complications such as hemorrhage.

Question 28

What physiological end-points should be improved in ICU management?

Answer 28

Lactate, SvO2, Urine output, Haemodynamics, Resolution of acidaemia ## Footnote These parameters provide insight into the patient's metabolic and hemodynamic status.

Question 29

When should inotropic support be provided?

Answer 29

Once intravascular volume replete ## Footnote Ensuring adequate volume is essential before initiating inotropic therapy.

Question 30

What condition should be monitored for in ICU care?

Answer 30

Monitor for ACS ## Footnote Acute coronary syndrome can arise in critically ill patients.

Question 31

What should be recognized to avoid missed injuries?

Answer 31

Recognition of occult injury ## Footnote This involves being vigilant for injuries that may not be immediately apparent.

Question 32

What type of survey should be conducted to ensure thorough assessment?

Answer 32

Tertiary survey ## Footnote A tertiary survey helps to identify any missed injuries or complications.

Question 33

What is an important step in further evaluation post-op?

Answer 33

Further imaging ## Footnote Additional imaging may be necessary to assess for complications or injuries.

Question 34

What historical information should be reviewed in ICU care?

Answer 34

Review history ## Footnote Understanding the patient's history can guide management and identify risks.

Question 35

What immunization should be considered in ICU management?

Answer 35

Tetanus immunisation ## Footnote This is vital for preventing tetanus infection in patients with wounds.

Question 36

What are the five INTRAOPERATIVE steps of damage control laparotomy

Answer 36

1. Rapid entry Large midline incision 2. Control of haemorrhage Identification of all injuries/ Packing/Direct control +- Reconstruction (if possible) 3. Control of Contamination Repair defects/resected damaged segments/Drin or divert GI or GU injuries (e.g. pancreatic injury/biliary, T-tube/ ursostomy) 4. Copious Washout Washout all the contamination, clot etc. Try leave it dry as possible 5. Temporary Abdominal Closure

Question 37

What are the two objectives of relook laparotomy after damage control surgery? At what time window should this be done?

Answer 37

Ideally performed within 24-48h Re-explore for missed injury Reconstruction and definitively repair as needed

Question 38

What are the two optinos for delayed abdominal closure

Answer 38

1. Delayed Primary closure Usually possible within 24-48h 2. Secondary closure

Question 39

What are the 4 options for secondary abdominal closure after damage control laparotomy?

Answer 39

1. Mesh mediated closure Absorbable-biologic = Permacol, absorbable-synthetic = vicryl mesh 2. Skin only closure Accept incision hernia and plan staged repair 3. Split-thickness Skin Grafts on granulating bowel or mesh 4. Continuous VAC temporary closure until granulation occurs and grafting possible

Question 40

What is the standard time window in which a delayed primary closure of the abdomen may be achieved?

Answer 40

24-48 hours (although can be achieved later than this)