(Salvage) surgery to preserve physiology and to control haemorrhage. Permissive hypotension until haemorrhage control. DAMAGE CONTROL resuscitation ...
Damage control resuscitation
Alessandro Bacuzzi MD Anesthesia and Palliative Care
Director: Salvatore Cuffari Varese University Hospital
DAMAGE CONTROL resuscitation Damage control, a naval term, is defined as “the capacity of a ship to absorb damage and maintain mission integrity” by permitting only minimal emergency repairs at middle of the sea enabling the ship to reach the harbor docks for definitive repairs Warfare Manual. Department of the Navy. The Department: Washington (DC);1996 Damage control resuscitation can be defined as a systematic approach to patients with exsanguinating trauma, incorporating several strategies to reduce morbidity and mortality. This objective is achieved via minimizing the occurrence of fatal triad: - hypothermia - acidosis - coagulopathy
DAMAGE CONTROL resuscitation Goal : move patients to a multi-specialist care as early as possible Pre-hospital care
rehabilitation
SEVERE TRAUMA Trauma center
✓ Trauma networks ✓ Medical education and training ✓ Research and evaluation
DAMAGE CONTROL resuscitation EMERGENCY ROOM
Rapid control of hemorrhage
EMERGENCY ROOM
OPERATING ROOM
OPERATING ROOM
Resuscitation in ICU
ICU
DEATH
Susequent reesploration
OPERATING ROOM
The goal of damage control resuscitation is to restore nomal physiology
ICU
DAMAGE CONTROL resuscitation 1
2
3
4
5
• Assessment and initial management
• Management of respiratory and haemodynamic failure
• EFAST ( extended focus assessment with sonography for trauma) to augment clinical assessment
• Major haemorrhage protocol activation. Peripheral + Central intravenous access + arterial line + fluid + vasopressor resuscitation + trasfusion protocol
• Tourniquet – pelvic binders
A (airway): assess the upper respiratory airway; B (breathing): look for signs of respiratory distress; C (circulation): look for signs of circulatory distress; D (disability): look for neurologic problems.
DAMAGE CONTROL resuscitation A (airway): assess the upper respiratory airway;
Haemostatic resuscitation
B (breathing): look for signs of respiratory distress;
Limited use of crystalloids and colloids to avoid dilutional coagulopathy
C (circulation): look for signs of circulatory distress;
Damage control (Salvage) surgery to preserve physiology and to control haemorrhage
D (disability): look for neurologic problems.
Permissive hypotension until haemorrhage control
Damage control resuscitation It is reasonable to apply individual aspects of this approach initially and escalate or step back as more information regarding injuries and response becomes apparent.
Damage control resuscitation/surgery
Damage control resuscitation (DCR) is a more recent development of the DCS concept. DCR describes the extension of the damage control principles beyond surgery, including resuscitation strategies spanning the pre-hospital care through to the operating room and intensive care unit. The principle aim of DCR is to define a systematic approach to major trauma in order to minimize blood loss and ultimately optimize outcome
Permissive hypotension until haemorrhage control
Permissive hypotension until haemorrhage control Low volume resuscitation ≠ no volume resuscitation
Permissive hypotension until haemorrhage control In massively bleeding patients, raising blood pressure to normal levels before achieving surgical hemostasis has been shown to increase bleeding by displacing clots formed during the body’s attempt of primary hemostasis The concept of delayed fluid administration in trauma is not new. In the early 1990s a randomised controlled trial of immediate (pre-hospital) versus delayed fluid administration in patients with penetrating truncal injuries demonstrated decreased morbidity (including systemic inflammatory response syndrome, pulmonary oedema and thrombocytopaenia) and mortality in the delayed resuscitation group as well as a shorter hospital stay
Further work is necessary to clearly delineate in what situations permissive hypotension should be rigorously applied but as with much of DCR decision making should be individualized.
Permissive hypotension until haemorrhage control
Haemostatic resuscitation Fluid theraphy using crystalloid solution should be initiated in the hypotensive bleeding trauma patients
Use of colloids must be restricted due to the adverse effects on haemostasis
Hypotonic solutions such as Ringer’s lactate be avoided in patients with severfe head trauma
Haemostatic resuscitation BLOOD VICIOUS CYCLE
Deeper hypotension
Hypotension
This cyclical crystalloid resuscitation rapidly leads to a severe dilutional coagulopathy Re-bleeding
Fluids bolus
Haemostatic resuscitation The concept centres around the assumption that coagulopathy is present very early after severe injury and rapidly corrective interventions can improve outcomes. This requires us to rethink our concept of massive transfusion and massive transfusion protocols.
Massive transfusion has traditionally been defined as those patients requiring more than 10 units of red cells in 24 h.
Local protocols will vary but Haemostatic resuscitation aims to deliver a mixture of red blood cells (RBCs), fresh frozen plasma (FFP) and platelets in approximately a 1:1:1 ratio
Haemostatic resuscitation
Plasma
Inibitori trombina
Fattore VII
Fibrinogeno e crioprecipitato
Inibitori Fxa
Tromboprofilassi
Piastrine
Concentrato protrombinico
GDT
Calcio
Desmopressina
Agenti antipiastrinici
Haemostatic resuscitation
Haemostatic resuscitation
Hypothermia
WARM
Passive external rewarming— achieved by warm blanketsor increasing room temperature.
REWARMING
Active external rewarming— through the use of force air-warming devices and other heaters. Active internal core warming— warming administered fluids and potentially the use of heated oxygen. Warmed bladder and peritoneal irrigation, arteriovenous rewarming and even haemodialysis
Acidosis
Fluid replacement
Bleeding control
Avoid confudent factors (ketoacidosis …)
REVERSE METABOLIC ACIDOSIS
Administration of sodium bicarbonate has been shown to cause the production of carbon dioxide, paradoxically lowering intra cellular pH and leading to a fall in the ionised calcium concentration which has implications for coagulation and cardiac function. Tris(hydroxymethyl) aminomethane leads to a similar effect by accepting hydrogen ions and it’s use has been reported in trauma patients
Acidosis
decreases cardiac contractility
attenuates adrenergic receptor responsiveness
impairs kidney perfusion
impairs coagulation by reducing thrombin generation
accelerating fibrinogen degradation
weakens the interplay of coagulation factors with activated platelets.
reduced availability of fibrinogen
Damage control (Salvage) surgery Damage control surgery should be employed in the severely injured patient presenting with deep haemorrhagic shock, signs of ongoing bleeding and coagulopathy. Severe coagulopathy, hypothermia, acidosis, inaccessible major anatomic injury, a need for time consuming procedures or concomitant major injury outside the abdomen should also trigger a damage control approach. Primary definitive surgical management should be employed in the haemodynamically stable patient in the absence of any of these factors
BUNDLE
simple imaging
Act rapidly and harmony
Coordinateed trauma team
ASSUME CONTROL
Conclusions The “lethal triad” of acidosis, hypothermia, and coagulopathy.
