Chp12DamageControl.pdf

Damage Control Surgery

Chapter 12

Damage Control Surgery

Introduction

The traditional approach to combat injury care is surgical

exploration with definitive repair of all injuries. This approach

is successful when there are a limited number of injuries.

Prolonged operative times and persistent bleeding lead to the

lethal triad of coagulopathy, acidosis, and hypothermia,

resulting in a mortality of 90%.

Damage control is defined as the rapid initial control of

hemorrhage and contamination, temporary closure,

resuscitation to normal physiology in the ICU, and

subsequent re-exploration and definitive repair. This

approach reduces mortality to 50% in some civilian

settings.

What might increase the life and limb salvage rate in troops

in the field setting is the application of the damage control

concepts described above in patients with favorable

physiology.

Tactical Abbreviated Surgical Control (TASC).

ο Damage control techniques in a tactical environment.

ο Abbreviated, focused operative interventions for peripheral

vascular injuries, extensive bone and soft tissue injuries,

and thoracoabdominal penetrations in patients expected

to survive, instead of definitive surgery for every casualty.

ο This may conserve precious resources, such as time,

operating table space, and blood.

This TASC philosophy relies on further definitive surgical

care at the next echelon of care.

12.1

Emergency War Surgery

Damage control techniques should be considered in all multi-

system casualties at the onset of surgical therapy. When initially

rejected, reconsideration should occur when unexpected

findings are discovered or natural breaks in the surgical therapy

occur, following an initial decision to perform a definitive repair.

The goal of damage control is to restore normal physiology

rather than normal anatomy. It is used for the multiple injured

casualty with combinations of abdominal, vascular, genitou-

rinary, neurologic, orthopedic, and/or thoracic injury in three

separate and distinct phases :

1. Primary Operation and Hemorrhage Control – surgical

control of hemorrhage and removal of contamination;

laparotomy terminated, abdomen packed and temporary

closure; definitive repair is deferred.

2. Critical Care Considerations – normal physiology restored

in ICU by core rewarming, correction of coagulopathy, and

hemodynamic normalization.

3. Planned Reoperation – re-exploration to complete the

definitive surgical management or evacuation.

General Considerations

Philosophy of damage control is “a live patient above all else.”

ο Avoid hypothermia.

ο Rapidly achieve hemostasis.

ο Perform only essential bowel resections.

ο Close or divert all hollow viscus injuries, only performing

reconstruction at the second operation after the patient has

stabilized and can tolerate a prolonged operation.

When to employ damage control.

ο Use damage control in patients who are present with or at

risk for developing:

♦ Multiple life-threatening injuries.

♦ Acidosis (pH < 7.2).

♦ Hypothermia (temp < 34AC).

♦ Hypotension and shock on presentation.

♦ Combined hollow viscus and vascular or vascularized

organ injury.

♦ Coagulopathy (PT > 19 sec and/or PTT > 60 sec).

12.2

Damage Control Surgery

♦ Mass casualty situation.

ο Take into account ability to control hemorrhage, severity

of liver injury, and associated injuries.

ο Pack before massive blood loss (10–15 units of pRBCs) has

occurred.

ο Injuries that typically require damage control techniques.

♦ Upper abdominal injuries that are not isolated spleen

injuries (duodenal, large liver injuries, pancreas, and

so forth).

♦ Major penetrating pelvic trauma of more than one

system.

♦ Any retroperitoneal vascular injury.

To reiterate, damage control is practiced in three phases:

1. Primary operation and hemorrhage control.

2. Critical care resuscitation.

3. Planned reoperation.

Phase 1: Primary Operation and Hemorrhage Control

Phase 1 of damage control includes 5 distinct steps:

1. Control of hemorrhage.

2. Exploration to determine extent of injury.

3. Control of contamination.

4. Therapeutic packing.

5. Abdominal closure.

Control of hemorrhage/Vascular injury repair.

ο Control of hemorrhage is best done with ligation, shunting,

or repair of injured vessels as they are encountered.

ο The primary goal is hemorrhage control, not maintenance

of blood flow.

ο For the patient in extremis, clamping or shunting of major

vessels is recommended over repair.

♦ THINK: ligate/shunt ⇒ fasciotomy.

ο Additional methods of hemorrhage control include balloon

catheter tamponade of vascular or solid viscus injuries.

Exploration to determine extent of injury.

ο Damage control laparotomy.

♦ Rapidly achieve hemostasis.

12.3

Emergency War Surgery

♦ Perform only essential resections or pack solid organs

to diminish blood loss.

♦ Close or divert all hollow viscus injuries.

♦ Rapidly terminate the procedure to correct hypo-

volemia, hypothermia, and acidosis to prevent

coagulopathy.

♦ Perform definitive reconstruction only after the patient

has stabilized and can tolerate a prolonged operation.

Control of Contamination.

ο Contamination control also proceeds as injuries are

encountered, utilizing clamps, primary repair or resection

without reanastomosis.

ο With multiple enterotomies, if the area of injury represents

less than 50% of the length of the small bowel, a single

resection can be undertaken.

ο At this stage of the operation, the surgeon must decide

whether or not to proceed with definitive repair of the

identified and controlled injuries. Careful communication

with the anesthesiologist is critical to this decision.

♦ If aggressive resuscitation has been successful in

maintaining normal temperature, coagulation, and acid

base status, then definitive repair may proceed.

♦ If any of these interrelated factors are abnormal, the

procedure should be terminated (contamination

controlled without reanastomosis) and the patient taken

to the ICU for further resuscitation.

♦ The presence and status of extra-abdominal injuries

needs to be taken into consideration when deciding how

much physiologic reserve the patient has left.

Therapeutic Packing.

ο Resuscitative vs Therapeutic Packing.

♦ Resuscitative packing is manual compression of the

bleeding site as an initial measure in controlling or

minimizing blood loss.

♦ Therapeutic packing provides long-term tamponade of

liver, pelvic, and retroperitoneal bleeding.

ο Do not use the “pack and peek” technique wherein the

liver is packed and the patient resuscitated; the packs are

removed to identify the source of bleeding, but rebleeding

12.4

Damage Control Surgery

occurs before the site can be identified; the liver is packed

again; the patient is resuscitated again; and the entire cycle

is repeated.

ο Definitive therapeutic packing is based on three basic

principles.

♦ Pressure stops bleeding.

♦ Pressure vectors should recreate tissue planes (attempt

to recreate the pressure vectors created by the capsule

of a solid organ or fill the space of that organ, not

random pack placement).

♦ Tissue viability must be preserved.

ο 6–12 laparotomy pads are the best commonly available

packing material.

ο An intervening layer, such as a bowel bag, sterile drape,

absorbable mesh, or omentum, can be placed between

packs and the tissue to aid in easy pack removal at

relaparotomy.

Abdominal Closure.

ο Leave the fascia open.

ο Vacuum pack (preferred technique — easy, keeps patient

dry, allows for expansion).

♦ With fascia open, place fully plastic-covered (bowel bag,

X-ray cassette bag, Ioban drape) sterile operating room

(OR) towel circumferentially under the fascia to cover

the viscera. Place a small number of central perforations

to allow fluid to egress to the drains.

♦ Place closed-suction drains (Jackson-Pratt, modified

Foley, small chest tube) above the plastic at the level of

the subcutaneous tissue brought out through separate

stab wounds or the inferior portion of the wound.

♦ Place lap sponges to fill in the wound.

♦ Cover the entire wound with a large Ioban drape.

♦ Place drains on low suction and secure to the skin.

ο A silastic sheet or 3-liter IV bag, sewn to the skin or fascia,

can accomplish abdominal closure in virtually every

instance.

ο Skin closure is not recommended, but may be quickly

accomplished with skin staples, towel clips (reliably

stronger), or running monofilament suture.

12.5

Plik z chomika:

Inne pliki z tego folderu:

Inne foldery tego chomika: