DAMAGE

CONTROL
RESUSCITATI
Arifin Muhammad
Siregar

ON
 Definition

Damage control resuscitation

(DCR) is a more recent concept. It
has variously been defined as Damage control surgery (DCS) is an
proactive early treatment to operative strategy that aimed at
address the lethal triad (by rapid restoring normal physiology over
reversal of acidosis, prevention of restoring normal anatomy in the
hypothermia and coagulopathy) on unstable, trauma patient
admission to combat hospital.
 The damage control concept is an essential component in the management of severely injured patients

THE Abbreviated surgical procedures limited to

PRINCIPLES
haemorrhage and contamination control

Correction of physiological derangements

Definitive surgical procedures

Jeremy M. Hsu, Tam N. Pham. Damage control in the injured patient. Department of Surgery, University of Washington, Harborview Medical Center. 2011
 Lethal
Triad
• In 1982, Kashuk and his colleagues emphasized the
importance of coagulopathy in their clinical review of 161
patients with major abdominal vascular injury

• Downward spiral : further deteriorates

hemorrhage
Kashuk JL, Moore EE, Millikan JS, Moore JB. Major abdominal vascular
trauma--a unified approach. J Trauma. 1982;22(8):672‐679.
doi:10.1097/00005373-198208000- 00004
 Coagulopa
thy
• “Resuscitation-associated coagulopathy”

• Lethal Triad: “vicious cycle of trauma” or the “bloody

vicious cycle”

• Trauma induced coagulopathy

 Resuscitation-associated
coagulopathy
• Large amounts of fluids and blood products
hypothermia
•
• Hypothermia
Inadequate tissue platelet dysfunction
anaerobic and reduced
metabolism
enzyme activities
perfusion acid lactic
• 0.9% normal saline
• Reduced activity of
most
VIIa of the
,Xa,V
coagulation factors
a)
with acidosis( Factor
*Bad blood: A coagulopathy associated with trauma and massive transfusion review:Tawnya Vernon,
Madison Morgan, and Chet Morrison Acute Medicine & Surgery 2019; 6: 215–222
 Trauma Induced
Coagulopathy
• Presents as increased coagulation activation, coagulation
impairment, and
increased fibrinolysis
• In fibrinolysis, tPA and the precursor plasminogen bind to
fibrin, leading tPA to activate and turn plasminogen into
plasmin.
• Plasmin then cuts the fibrin and rapidly degrades the clot
• Hyperfibrinolysis is often seen in trauma patients, and
historically is a 60– 100% predictor of mortality in
trauma patients
Midwinter MJ, Woolley T. Resuscitation and coagulation in the severely
injured trauma patient. Philos Trans R Soc Lond B Biol Sci. 2011;366(1562):192‐203.
doi:10.1098/rstb.2010.0220
 Damage control resuscitation integrates permissive
hypotension, hemostatic resuscitation, and damage
control surgery
Early use of blood product over isotonic fluid for
volume replacement

Damage Cont Early correction of coagulopathy with components,

rol Resuscita ie. Massive transfusion protocol (PRBCs: FFP: Platelet
tion = 1:1:1)
Satisfied with MAP = 50-60mmHg
 Balanced
• “Injection of aResuscitation
fluid that will increase blood pressure has
dangers in itself. … If the pressure is raised before the
surgeon is ready to check any bleeding that might take
place, blood that is sorely needed may be lost”

— Walter Cannon. JAMA 1918;70(9): 620

• Aggressive crystalloid-based resuscitation
• cardiac and pulmonary complications
• gastrointestinal dysfunction
• coagulation disturbances
• disorders of immunological and inflammatory mediators
 Balanced
Resuscitation
• Its 3 basic tenets are
• Permissive hypotension
• Minimizing the use of crystalloid before surgical control
of bleeding
• Transfusion of blood products in a ratio approximating
whole blood

• Imbalances of intracellular and extracellular osmolarity that

affect cell volume
 Haemostatic
resuscitation
• PROMMTT study (2013) Higher plasma and platelet ratios
early in resuscitation were associated with decreased
mortality in patients who received transfusions of at least 3
units of blood products during the first 24 hours after
admission ( Survivor bias ?)

• The PROPPR trial (2015) found no statistically

significant mortality difference on the primary outcome
of mortality between massive transfusion protocols based
on 1:1:1 and 2:1:1 ratios. There was an absolute difference
in mortality of about 4% favouring the 1:1:1 ratio, but the
study was not powered to detect this. A post-hoc
secondary outcome of death by exsanguination in the
 Rewarmi
ng
• Passive warming measures
• insulting foil
• Blankets
• Removal of wet clothes
• The Initial fluid resuscitation- 40–42 °C
• Warming measures:
• Heated air inhalation,
• gastric or body cavity lavage with warmed fluids
• heat radiation
• Operating room should be raised, at best to a
thermally neutral
• range (28–29 °C)
 Reversing
Acidosis
• Buffering of metabolic acidosis using drugs NOT
RECOMMENDED (aggravates the intracellular
acidosis but also does not reverse the coagulopathy)
• Fluid and blood resuscitation
• Vasopressor support
• Surgical control of hemorrhage
• Base deficit and lactate levels are the reliable
indices with which to
evaluate the adequacy of the resuscitation and end-
organ perfusion.
 Tranexamic
acid
• Antifibrinolytic agents
• CRASH-2: All-cause mortality and the risk of death due to
bleeding were significantly decreased with the
administration of tranexamic acid. Maximal beneficial effects
were achieved if it was given within the first 3 h of injury
• MATTERs and MATTERs II Trials : Mortality was lowest
in the TXA-plus group (11.6%) and TXA-only group
(18.2%) compared with the cryoprecipitate-only group
(21.4%), and neither TXA nor cryoprecipitate group
(23.6%)
 Tranexamic
acid
• Loading Dose: 1 gm in 100 mL saline infused over 10
minutes
• Maintainance dose: 1gm mixed in 500 mL saline infused
over 8 hours
• Adverse effects: Hypotension, dizziness, allergic
dermatitis, nausea, vomiting, diarrhea, color changes,
seizures (reported with high doses), ureteral obstruction
• T1/2: 2-11 hours
• Excretion: Urine(> 95%)
• Contraindications:
• Allergy to tranexamic acid
• Defective color vision
 Fibrinogen (plus
Reduced fibrinogen
platelets) is the
levels correlate with
primary substrate
increased mortality
for clot formation

Cryoprecipita
te
Contains: If fibrinogen is
Fibrinogen, Factor <1.0g/L give
VIII, vWF, Factor XIII Cryoprecipitate
 MT
P

• Def: defined as the transfusion of 10 or more units of

PRBC within the first
24 h of injury

• Total blood volume is replaced within 24

hours

• 50% of total blood volume is replaced

within 3 hours

• Rapid bleeding rate is documented or

 MT
P
• Protocol:
• Patient selection for activation
• Description of the staff
• Blood bank are informed
• Cooled packs of O negative RBCs, type AB FFP, and platelets will
be pre-packed for quick delivery
• A high-ratio pack is continually delivered each time blood is
requested until the
protocol is deactivated
• Type-specific blood will be delivered as soon as the patient’s blood
type is determined
 MT
P
• The MTP is bundled with the
• administration of calcium
• factor VIIa
• fibrinogen.
• The laboratory examination of coagulation-
TEG

• Score for prediction of patients who

require MTP
• TASH
• ABC
• TBSS
DCS Operative Principles

The goal of DCS is a

short operating time, Control of Control of
Prevent hypothermia
followed by transport hemorrhage contamination
to ICU

Restoration of
Temporary closure Angiography/
homeostasis in the
(TC) embolization
intensive care unit
STAGE 1st DCS (THORAX)

For thoracic injuries requiring DCS several options exist

Bleeding peripheral pulmonary injuries  wedge resection using a stapler is performed.
In penetrating injuries  pulmonary tractotomy is used to divide the parenchyma
Individual vessels and bronchi are then ligated using a 3-0 polydioxanone suture (PDS) and the
track left open.
Cardiac injuries may be temporarily controlled using a running 3-0 nonabsorbable polypropylene
suture or skin staples.
Pledgeted repair should be performed for the relatively thin right ventricle.
Return to the OR within 24 hours is planned once the patient clinically improves, as
evidenced by normothermia, normalization of coagulation test results, and correction of
acidosis.
 The surgical procedure is restricted to a bare minimum.

The procedure is finalized with a temporary closure of organs

due to numerous factors that makes impossible abdominal
correct closure.
STAGE 2nd
DCS Begins in ICU  The next 24 to 48 hours are crucial :

• Correction of metabolic disorder

• Core rewarming
• Correction of coagulopathy and Complete ventilatory support
• Correction of acidosis
• Identification of occult injury
STAGE 3rd DCS
PLANNED REOPERATION

Window of opportunity is 24-48 hours after the trauma- between the correction of
metabolic disorder and the onset of SIRS and MOF
Removal of the bleeding control packs (48-72 h)
Primary repair with end-to-end anastomosis undertaken
Copious washout should be performed and the abdomen closed
The patient sometimes needs early unplanned reoperation-ongoing haemorrhage,
abdominal compartment syndrome or peritontis
 DISADVANTAGES of DCS

1. Sepsis and multi organ failure

2. Pneumonia

3. Infection

4. Enteric fistula

5. Compartment syndrome
INDICATIONS FOR DEFINITIVE
SURGERY

1. Core 2. Correction of
temperature acid base
36°C or above balance

3. Normalization
of coagulation
profile.
 Referenc
•
es
Mizobata Y. Damage control resuscitation: a practical approach for severely hemorrhagic patients and its effects
on trauma surgery. Journal of Intensive Care. 2017 Dec 1;5(1):4.
• Cantle PM, Cotton BA. Balanced resuscitation in trauma management. Surgical Clinics. 2017 Oct 1;97(5):999-1014.

• Midwinter MJ, Woolley T. Resuscitation and coagulation in the severely injured trauma patient. Philosophical Transactions of
the Royal Society B: Biological Sciences. 2011 Jan 27;366(1562):192-203.

• Boukerrouche A. Modern Trauma Care: Damage Control Surgery and Damage Control Resuscitation-Brief Report. EC Emergency
Medicine and Critical Care. 2020 Jan 3;4(2):01-4.

• Cai J, Ribkoff J, Olson S, Raghunathan V, Al‐Samkari H, DeLoughery TG, Shatzel JJ. The many roles of tranexamic acid: An
overview of the clinical indications for TXA in medical and surgical patients. European journal of haematology. 2020
Feb;104(2):79-87.

• Weymouth W, Long B, Koyfman A, Winckler C. Whole blood in trauma: a review for emergency clinicians. The Journal of
emergency medicine. 2019 May 1;56(5):491-8.

• Brunicardi, F., Andersen, D., Billiar, T., Dunn, D., Hunter, J., & Kao, L. Et Al. SCHWARTZ'S PRINCIPLES OF SURGERY 2-
volume Set 11th Edition.

• Leibner E, Andreae M, Galvagno SM, Scalea T. Damage control resuscitation. Clin Exp Emerg Med. 2020;7(1):5-13.
doi:10.15441/ceem.19.08

• Jansen JO, Thomas R, Loudon MA, Brooks A. Damage control resuscitation for patients with major trauma. BMJ.
2009;338:b1778. Published 2009 Jun 5. doi:10.1136/bmj.b1778

• Gonçalves, Roberto and Saad, RobertoThoracic damage control surgery. Revista do Colégio Brasileiro de Cirurgiões [online].
2016, v. 43, n. 05 [Accessed 29 August 2021] , pp. 374-381. Available from: <https://doi.org/10.1590/0100-69912016005017>.
ISSN 1809-4546. https://doi.org/10.1590/0100-69912016005017.