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Damage control surgery

Up Damage control surgery DPL


Rationale

  • Severe trauma is associated with severe bleeding, coagulopathy, acidosis and hypothermia
  • Both acidosis and hypothermia exacerbate coagulopathy resulting in increased bleeding
  • Hypovolaemia will exacerbate acidosis
  • Blood transfusion will exacerbate hypothermia and coagulopathy
  • Laparotomy is associated with considerable heat loss and both acidosis and hypothermia are difficult to correct intra-operatively
  • Prolonged attempts at definitive repair of injuries may, therefore, result in a patient entering a downward spiral of progressive bleeding
  • Aim of damage control surgery is to:
    • stop bleeding
    • provide simple closure of hollow viscera perforation

Components

  1. stop bleeding, close perforations
  2. continue resuscitation with an emphasis on correction of coagulopathy, acidosis and hypothermia
  3. planned re-operation for definitive repair

Indications

Recommended for severely injured patient with:

  • severe haemorrhagic shock
  • signs of on-going bleeding
  • coagulopathy
  • hypothermia
  • acidosis
  • inaccessible major anatomic injury
  • need for time-consuming procedures
  • concomitant major injury

ICU management

  • continue resuscitation with an emphasis on correction of coagulopathy, acidosis and hypothermia
  • monitor for development of complications. High risk of abdominal compartment syndrome

Emergency re-operation

Indications:

  • massive on-going bleeding (eg >2 units per hour for 3 hours, particularly in a warm non-coagulopathic patient)
  • evidence of bowel leak or ischaemic organ
  • abdominal compartment syndrome (risks of profuse bleeding from loss of tamponade effect must be weighed against risks of continued intra-abdominal hypertension)

Futher reading

Spahn DR et al. Management of bleeding following major trauma: a European guideline. Crit Care, 2007; 11:R17 

Sagraves SG et al. Damage control surgery - the Intensivist's role. J Intensive Care Med, 2006; 21:5-16


©Charles Gomersall, April, 2014 unless otherwise stated. The author, editor and The Chinese University of Hong Kong take no responsibility for any adverse event resulting from the use of this webpage.
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