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 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
/ TKO fluid)
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
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
Factor VIIa
Expensive
Forms clot-good and bad
No great data supporting its use; certainly no
mortality benefit
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
NP
Julie Larsen, NP
Liz Marble, NP