01_Cook_Damage Control Resuscitation 2

Damage Control Resuscitation

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, MDUVRMC Trauma Medical

Director

Damage Control Resuscitation is…

The active conscious process to restore and/or maintain blood volume, appropriate thrombogenesis, and tissue oxygenation which allows for adequate end organ perfusion in the bleeding patient.

Damage Control Resuscitation is NOT…FancyEasy or effortlessIndividual or unilateralHigh volume crystalloid resuscitationMucking around with central lines or cut-downsLong OR timesComplex reconstructive procedures “early on”Long transfer times or multiple transfers

Damage Control Resuscitation IS…

Early control of hemorrhageRapid transport to definitive careLimited crystalloid infusionEarly and liberal use of blood products in approximation of

whole blood (1:1:1)Permissive hypotension (excluding TBI/SCI patients)Judicious and early use of tourniquets, pelvic binders, splints,

compressive dressings/direct pressureQuick peripheral large bore IVFocusing on and addressing ABC’s using available adjuncts

(FAST, CXR, Pelvic X-ray)

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 surgeryPelvic bindersTourniquetsPrevention/treatment of hypothermiaDrugs

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 deformityTaken to small, local hospital with multiple

complaintsNumerous plain films of extremities obtained

before patient sent for CT scans

Case Review

20 gauge IV started in her handWhile in CT, the patient developed hypotension; systolics

in the 70’sBP came up with three liters of crystalloidAfter CT report generated, transfer arrangements initiatedNearly 6 hours after the accident, the patient arrived at

closest trauma centerPatient lethargic, clammy, and hypotensiveHad received at least 4 liters of crystalloid prior to arrivalPelvic 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 stableFemur, then pelvis repairedDischarged 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 patient’s body will take the following steps to protect itself from further blood loss• Vasospasm• Clot formation; initially quite weak/tenuous

What’s been our first response to a hypotensive trauma patient?

Two large bore IVs and two liters of crystalloid bolused as fast as possible

What are the consequences of that crystalloid bolus?Blood pressure goes up

• Just what we want, right?

Blood vessels get stretchedPotentially “popping” the clot

New Pre-hospital IV Fluid Recommendations for Trauma

1. Stop visible bleeding2. Assess for shock

• Signs of shock:– Hypotension (SBP<90)– Loss of radial pulse – Decreased mental status

New Pre-hospital IV Fluid Recommendations for Trauma

If not in shock: • No IV fluids necessary• Intact radial pulse, SBP ≥ 90,

normal mental status• Start saline lock (or extension set

/ TKO fluid)Rapid transport to Trauma Center/EDMonitor carefully for shock

New Pre-hospital IV Fluid Recommendations for Trauma

If in shock:• 500 – 1000 cc crystalloid bolus• Reassess• Repeat bolus if necessary

Goal: increase perfusion, SBP ≥ 90• Goal is not “normal BP”

Rapid transport to Trauma Center/ED

Other Important Considerations

Short scene times (< 10 minutes)• Limited scene interventions

Work in back of ambulance en route to Trauma Center/ED

Patients with hypotension and head injuries are particularly challenging to care for as crystalloids can potentiate cerebral edema

Note: these are adult recommendations

PERMISSIVE HYPOTENSIONTRAUMATIC 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

What about once we get the patient to the hospital?

Blood product transfusion is administered ASAP and very well may be life saving in patients with persistent shock and/or ongoing blood loss

How are blood products to be utilized in the resuscitation of the bleeding trauma patient?

Is the blood on the floor just red blood cells?

Whole blood consists of red cells, plasma, platelets, coagulation factors, etc…

If all we give back are red blood cells, we are leaving out some other important components and are further diluting the “other parts” of the circulatory volume

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)

RecipeThey 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 PRBC’s 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

Evidence for Benefit of Early Blood Products: Military Combat Experience

Improved survival and decreased complications• Holcomb J Trauma 2003;54(5 Suppl):46

Improved survival and decreased multi-organ failure • Holcomb, et al Ann Surg 2008;248:447

Evidence for Benefit of Early Blood Products: Civilian Experience

One civilian study showed an 80% to <30% mortality decrease with implementation of 1:1:1 massive transfusion

Decreased transfusion requirements• Duchense, et al J Trauma 2009;67:216

Excellent current review of IV fluid resuscitation• McSwain, et al J Trauma 2011;70 (5 Suppl):S2

What is the Massive Transfusion Protocol (MTP)?

The Massive Transfusion Protocol is an attempt to streamline the process of getting blood products into the exsanguinating patient from the blood bank in an orderly manner and in optimal ratios

The protocol is written such that upon its initiation, blood products will be prepared, delivered, and transfused in a manner consistent with our goal of 1:1:1

Massive Transfusion Protocol (MTP)

What is the Massive Transfusion Protocol (MTP)?What triggers the initiation of the MTP at

UVRMC?What are the related consequences of the MTP?

PRINCIPLES OF DAMAGE CONTROL SURGERY

H. Stone, 1983 : first described principleM. Rotondo, 1993: coined the term and

demonstrated outcome advantage

Stage 1: Abbreviated initial procedurea. control hemorrhageb. control contaminationc. temporary closure

Stage 2: Continued resuscitation in ICUa. reverse hypothermia, acidosis,

coagulopathyStage 3: Definitive repair and closure – return to

OR

TRANEXAMIC ACID (TXA)

Fibrinolysis = normal process by which body breaks down blood clots

Overactive fibrinolysis is common in traumaTXA is an anti-fibrinolytic agent which decreases

breakdown of clot and decreases blood lossEarly TXA should be given for any patient

requiring massive transfusion for trauma related hemorrhage

Mortality benefit as per CRASH 2 trial

Factor VIIa

ExpensiveForms clot-good and badNo great data supporting it’s use; certainly no

mortality benefit

DAMAGE CONTROL RESUSCITATION: Additional PrinciplesNot intended for all patients; just the severely

injuredIs a continuum from pre-hospital to definitive

care• Scene Transport ER ICU OR

Early identification of those requiring DCR is imperative

Over-resuscitation can be nearly as harmful as under-resuscitation

DAMAGE CONTROL RESUSCITATION IN REVIEW1. Permissive hypotension 2. Limit crystalloids 3. Deliver blood components in physiologic ratios (close to

whole blood)4. Adjuvant therapies:Damage control surgeryPelvic bindersTourniquetsPrevention/treatment of hypothermiaDrugs

UVRMC Trauma APCs

Adam Phillips, PA-C Tom Asturias, PA-C

UVRMC Trauma APCs

Lindsey Anderson, NP

Julie Larsen, NP

UVRMC Trauma APCs

Liz Marble, NP