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SURGICAL DAMAGE CONTROL

SURGICAL DAMAGE CONTROL. Bradley W. Thomas, MD LCDR MC USN Constanta Trauma Symposium 12 JUNE 2013. OUTLINE. 1. Definition/description 2. Who needs it 3. Operative techniques 4. ICU techniques 5. Reoperation techniques 6. Expected outcome. Navy Definition. “ the capacity of a ship to

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SURGICAL DAMAGE CONTROL

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  1. SURGICAL DAMAGE CONTROL Bradley W. Thomas, MD LCDR MC USN Constanta Trauma Symposium 12 JUNE 2013

  2. OUTLINE 1. Definition/description 2. Who needs it 3. Operative techniques 4. ICU techniques 5. Reoperation techniques 6. Expected outcome

  3. Navy Definition “the capacity of a ship to absorb damage and maintain mission integrity” Naval War Publication 3-20.31, Dept Defense, 1996 (c/o Paul Possenti, PA-C, Bridgeport Hospital)

  4. Initial Damage Control Stages Stage 1: DC1 • Control hemorrhage • Limit peritoneal contamination • Temporary abdominal closure Stage 2: DC2 • Hypothermia prevention/treatment • Correction of coagulopathy • Correction of acidosis Stage 3: DC3 • Definitive surgery • May require multiple surgeries • Creation of ostomies, feeding access, fascial closure • No longer than 72 hours from Stage 1 • Data from Rotondo MF, Schwab CW, McGonigal MD, et al. ‘Damage control’: an approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma 1993;35(3):375.

  5. “Despite the lethality of injuries, if a wounded solider survives the rapid transport to a military medical facility with surgical capability, the likelihood of survival is now higher than any previous recorded conflict.” Eastridge BJ, Jenkins D, Flaherty S, et al. Trauma system development in a theater of war: experiences from Operation Iraqi Freedom and Operation Enduring Freedom. J Trauma 2006;61(6):1366.

  6. Lethal Triad

  7. WHO NEEDS DAMAGECONTROL?Intraoperative Sequelae of Shock • Initial or persistent hypothermia • Initial or persistent metabolic • Acidosis • Nonmechanical bleeding * * * * * • “metabolic failure”

  8. WHO NEEDS DAMAGE CONTROL? DISTINGUISH BETWEEN GROUPS May Stabilize Temp 35C pH > 7.2 BD > -10 Near-Exsanguinated Temp < 34C pH < 7.1 BD -15 -20 HR/SBP>0.9

  9. WHO NEEDS DAMAGE CONTROL? Distinguish Between Groups Near-exsanguinated Maystabilize ↓ ↓ Stophemorrhage Stophemorrhage ↓ Damagecontrol ↓ Considerdef. operation

  10. DAMAGE CONTROL Control Visceral Hemorrhage 1. Spleen 2. Liver 3. Pancreas 4. Kidney

  11. DAMAGE CONTROL Spleen GradeI-IIGradeIII-IV Repair→10-15min←Resect Repair→15-30min Immunity suppressed Immunity preserved

  12. SPLENECTOMY IS HARMFUL • Lose splenic filter • 2. Lose production of • 3. Lose immunosuppression IgM Tuftsin Opsonin Properdin

  13. DAMAGE CONTROL Spleen Surgicel/Avitene/Fibringlue Suture Vicrylmeshtamponade Perisplenicpacking

  14. DAMAGE CONTROL Liver Hasabloodsupplyof 1500ml/min Therefore,apoorlychosen damagecontroltechnique islikelytofailinthe coagulopathicpatient

  15. DAMAGE CONTROL Liver Compression Perihepatic packs Rawsurface Subc.hematoma Ballooncathetertamponade→Track Absorbablemeshtamponade→Fx

  16. DAMAGE CONTROL Liver Moreselective,buttime-consuming ResectionaldebridementwithS.V.L. HepatotomywithS.V.L.

  17. HEPATIC TRAUMAOmental Pack Control intrahepatic venous hemorrhage Manage dead space Bring mobile macrophages to site of injury H.H. Stone, 1975; H.L. Pachter, 1979; T.C. Fabian, 1980

  18. DAMAGE CONTROL Pancreas Controlperipancreaticsmall bleeders Suture Controlretropancreaticlarge bleedersDivide Deferdistalpancreatectomyto reoperation

  19. DAMAGE CONTROL Kidney Palpatenormalsizedkidney onoppositesidebefore performingneeded nephrectomy

  20. DAMAGE CONTROL Control GI Contamination Closeholes1layer,suture IsolateholesUmbilicaltapes ResectholesStapler SeverecolonColostomyatreop.

  21. DAMAGE CONTROL Control Arterial Hemorrhage Celiaca. Sup.mes.a. Renala. Ligate Shunt Nephrectomy Iliaca. Shuntorligate, fasciotomy,fem-fem

  22. DAMAGE CONTROL Control Arterial Hemorrhage DON’TIGNORELIKELYSEQUELAE X-clampabd.aorta,CIA,EIA→ Bilateraloripsilateralfasciotomy

  23. DAMAGE CONTROL Control Venous Hemorrhage Commonorexternal,Ligate iliac, infrarenal, IVC SMV, Portal Pelvic Veins Clamps, Tacks, Omentum Retrohepaticvenacava Pack

  24. Atriocaval Shunt

  25. DAMAGE CONTROL Venous Hemorrhage DON’TIGNORELIKELYSEQUELAE LigateportalveinorSMV Silo/NPDandreoperationat12 hours X-clamporligateinfrarenalIVC Bilateralfasciotomy

  26. Managing the Open Abdomen A simple but eloquent idea J.Trauma48:201-7,2000

  27. DAMAGE CONTROL ICU Phase Treatment of Hypothermia Standard Warming maneuvers Room, Head, Lung, Trunk, IVs Avoidconduction Avoidevaporation Keepbeddry Keepskindry

  28. DAMAGE CONTROL ICU Phase TREATMENTOF ACIDOSIS AcidosisuncouplesB-adrenergic receptorsatcellularlevel Testdose50-200mEqHC03ifpH< 7.2andpatientfailing

  29. DAMAGE CONTROL Reoperation Removalofpacks/Evaluatehemostasis *Checkformissedinjuries CompleteGIresections,repairs, reconstructionordiversion Passageofnasojejunalfeedingtube/ Formaljejunostomy Fascialclosurevs.VAC

  30. DAMAGE CONTROL Closure/Coverage Options 1. Components/modified 2. Biologic Mesh 3. Absorbablemesh,delayed STSG,leaveabighernia

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