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Trauma resuscitation and damage control surgery
EMERGENCY SURGERY
Trauma resuscitation and damage control surgery
(i) by a US group, as proactive early treatment to address the lethal triad (by rapid reversal of acidosis, prevention of hypothermia and coagulopathy) on admission to combat hospital.2 (ii) by a UK group as a systematic approach to major trauma combining the catastrophic bleeding, airway, breathing and circulation (ABC) paradigm with a series of clinical techniques from point of wounding to definitive treatment in order to minimize blood loss, maximize tissue oxygenation and optimize outcome. These two definitions while expressing the DCR concept differently amount to the same practical measures to achieve the aim of DCR, namely proactive management of the physiological consequences of the injury. The UK definition extends the DCR principle forward to the point of wounding and is a more generalized statement. However, central to both is early recognition and management of the physiological consequences of the injury. The principles of DCSeDCR are equally applicable in civilian as well as military trauma management. In each scenario more seriously injured victims of high-energy trauma are being delivered alive to trauma centres, due to rapid transportation (including by air ambulance) and advanced forward care. The concept of staged surgery to improve the survivability of major trauma has been described for over a century, as Pringle published a case series of packing liver injuries in 1908, and Calne in 1979 published a series of liver trauma patients whose abdomens were packed prior to transfer and definitive surgery at another centre. The impetus that has lead to the current acceptance of these principles however started in US trauma centres in the 1980s and 1990s, as Stone published his series of abdominal trauma patients treated with staged laparotomies in 1983, and Rotondo and co-workers published a further series and coined the phrase ‘damage control surgery’ in 1993. It is now recognized that severely injured trauma patients are more likely to die from the metabolic consequences of the injury rather than the completeness of the immediate surgical repair to damaged organs. While there has been academic recognition of the importance of addressing resuscitation and surgical issues concurrently, it is only with the development of the concept of DCR and emerging technological useful clinical tools, that this has been consolidated into practice. It is now timely to reassess both DCR and DCS.
C A Fries Mark J Midwinter
Abstract In recent years the envelope of survivability for victims of high-energy polytrauma has been continuously extended, thanks to advances at all levels of trauma care in both civilian and military practice. The concept of damage control surgery has been embraced by surgeons of various specialities as a paradigm within which to manage these patients, many of whom reach trauma centres alive, having sustained injuries which would until recently have been considered unsurvivable. This paper summarizes the development and application of this approach, and details the latest research evidence and development of this technique to include an integrated ‘Damage Control ResuscitationeDamage Control Surgery’ (DCReDCS) protocol. The traditional staged approach to DCS has been superseded by an integrated DCReDCS approach. This has been driven by a greater understanding of the management of the ‘lethal triad’ of trauma and by technological advances enabling real-time monitoring of physiological indices. This approach can extend initial safe operating times, with concomitant improvement in rates of survival and limb salvage.
Keywords Acute traumatic coagulopathy; damage control resuscitation; damage control surgery; massive transfusion protocols
Introduction Damage control surgery (DCS) is an operative strategy that sacrifices the completeness of the immediate surgical repair in order to address the physiological consequences of the combined trauma of the injury and surgery. In the past this has been very much focussed on abdominal trauma and the idea of performing an ‘abbreviated laparotomy’. However the concepts are applicable to injury beyond the abdomen, including the management of wounds, head injuries, maxillofacial trauma and fractures.1 Damage control resuscitation (DCR) is a more recent concept. It has variously been defined as:
Pathophysiology The central observation behind the philosophy of DCS is the adverse effects of the combined triad of hypothermia, acidosis and trauma-induced coagulopathy (TIC) (as a consequence of the hypothermia, acidosis, consumption and dilution of clotting factors) in trauma patients.1,2 Hypothermia leads to a-adrenergic stimulation with vasoconstriction, exacerbating any organ hypoperfusion, which may be already present secondary to hypotension from the injury. This leads to worsening acidosis. Both hypothermia and acidosis may be further exacerbated by aggressive fluid resuscitation, especially with normal saline. Hypothermia and acidosis combined with the consumption, dilution and failure to replace clotting factors lead to a coagulopathy. Even if major surgical
C A Fries MA MB BChir MRCS is Surgeon Lieutenant Commander Royal Navy, Surgical Trainee, University Hospitals Birmingham and Academic Department of Military Surgery & Trauma (ADMST), Birmingham, UK. Conflicts of interest: none declared. Mark J Midwinter BMedSci (Hons) DipAppStats MD FRCS(Eng) FRCS(Gen) is Surgeon Captain Royal Navy and Defence Professor of Surgery; Honorary Professor, School of Medicine, University of Swansea and Academic Department of Military Surgery & Trauma (ADMST), Birmingham, UK. Conflicts of interest: none declared.
SURGERY 28:11
563
Ó 2010 Elsevier Ltd. All rights reserved.
EMERGENCY SURGERY
bleeding is controlled at this stage the patient will continue to bleed form all cut surfaces prolonging the ‘bloody vicious cycle’ of hypothermia, acidosis and coagulopathy. The degree of coagulopathy is known to be underestimated by standard laboratory tests of coagulation. Hypothermia is directly correlated to injury severity and an independent risk factor for mortality, reaching 100% when core temperature is less than 32 C in patients undergoing a laparotomy. However, the contribution of acidosis, hypothermia and the dilution/consumption of clotting factors to the development of coagulopathy has been overstated.3,4 It has been recently recognized that in up to 30% of patients with major traumatic injuries there is an endogenous coagulopathy that is present early before significant fluid resuscitation and appears to be mediated through the activation of the protein C pathway.5,6 This acute traumatic coagulopathy (ATC) is induced by the combination of trauma, shock and tissue hypoperfusion. Patients who have evidence of ATC on admission to the emergency department are more likely to require massive blood transfusion, develop multiorgan failure and have up to fourfold chance of dying.5,7
UK military massive transfusion protocols (MTP) are based on administering units of PRBCs, FFP in a 1:1 ratio and early use of platelets, where an MTP approach is indicated, but quickly switching to being driven by real-time analysis of coagulopathy using thromboelastometry (TEM). TEM is a viscoelastic whole blood assessment of coagulation. Unlike classical coagulation tests such as prothrombin time (PT), international normalized ratio (INR) and activated partial thromboplastin time (APTT), TEM evaluates whole blood including the interaction between the clotting factors and platelets. It is a ‘near patient’ test in which results are expressed both graphically and numerically that allows the clinical staff to evaluate the clotting dynamics of initiation, propagation and amplification of thrombin generation and fibrin formation as well as fibrinolysis. This approach minimizes risk and facilitates the focussed administration of blood products and clotting factors.
Damage control surgery The decision to adopt a damage control approach to surgical intervention in a trauma patient should be reached early, in order to avoid the vicious cycle being entered, rather than employing DCS as a measure of desperation once the consequences outlined above are established; so-called ‘bail-out’ surgery. Physiological measures to define when a DCS approach should be adopted have been suggested (Box 1). Others have included lactate or base deficit, blood transfusion requirement or injury mechanism and complexes. Rotondo and Zonies identified key factors in patient selection under the headings of Conditions, Complexes and Critical Factors (Boxes 2e4). DCS is only applicable to a minority of trauma patients and if used too liberally may be no better or even worse than immediate definitive surgery. However, too strict a definition as to when to adopt the approach, particularly based on laboratory indices, can mean that the adverse physiological consequences are already established. Experience and rapid surgical assessment are key to making a positive, informed decision to adopt a DCS strategy. Classically five stages of DCS are described (Box 5).1
Damage control resuscitation These new insights into pathophysiological changes have influenced the approach to resuscitation. In patients with injury and massive haemorrhage, massive transfusion protocols have developed to counter the dilution and consumption of clotting factors and to addressing the hypothermia and acidosis. This was achieved primarily by transfusing plasma after a certain number of units of packed red blood cells (PRBC), combined with administering fibrinogen and platelets to correct TIC. The early presence of ATC before significant dilution or consumption of clotting factors has occurred, mandates early recognition and treatment. Recognition has been largely based on clinical indicators of injury severity and blood loss. These clinically based predictions perform with only about 80% sensitivity and specificity.8 Standard laboratory tests for coagulopathy are not sensitive for detecting ATC and have a significant lag behind the clinical picture due to the time delay in their performance. Treatment has been based on protocols with a ‘one size fits all’ approach. Use of blood and plasma can be associated with adverse outcomes other than just those potential risks from exposure to disease transmitted by blood products. There is evidence from a prospective multicentre cohort study in trauma patients who survive their initial injury, of fresh frozen plasma (FFP) transfusion being independently associated with multiorgan failure (MOF) and acute respiratory distress syndrome (ARDS).9 Also a pilot study in combat casualties has indicated that allogenic blood transfusion was associated with increased perioperative infection and impaired wound healing.10 However, haemostatic resuscitation during surgery with a high ratio of FFP to PRBC (around 1:1) in patients with TIC improves survival.5 These studies emphasize the requirement to make a rapid diagnosis, so appropriate treatment can be given to patients requiring haemostatic resuscitation and those patients not requiring such intervention are not exposed to the unnecessary risks. With recognition of the cell-based theory of clotting and the central role of the platelet and platelet surface for factor interaction, earlier use of platelets is recognized as important. Indeed current
SURGERY 28:11
Stage 1: Patient selection and decision making described above. This should occur rapidly either immediately preoperatively or within minutes of the start of surgery. Stage 2: Intraoperative stage. Priorities are haemorrhage control, limiting contamination and temporary closure or cover. Haemorrhage control may be achieved by ligation, suture,
Suggested physiological indications for the damage control surgery approach C C C
Systolic blood pressure less than 70 mmHg Core temperature less than 34 C pH less than 7.1
Box 1
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Ó 2010 Elsevier Ltd. All rights reserved.
EMERGENCY SURGERY
Patient selection conditions C C C C
Patient selection critical factors
High-energy blunt trauma Multiple torso penetration Haemodynamic instability Presenting coagulopathy and/or hypothermia
C C C C
C
Severe metabolic acidosis (pH 7.30) Hypothermia (temperature <35 C) Resuscitation and operative time >90 minutes Coagulopathy as evidenced by the development of non-mechanical bleeding Massive transfusion (>10 units of packed red blood cells)
Box 2 Box 4
tamponade (by packing or balloon), or shunting. Definitive vascular repair by grafting or anastomosis is not considered a DCS procedure. Contamination control is achieved by closure of the ends of the injured hollow viscus. Bowel ends are closed without attempt to regain gastrointestinal continuity, by tapes, staples or suture. The stomach may be similarly dealt with. Less accessible structures such as the duodenum and bile duct may be dealt with by simply placing drainage tubes to control leakage. Anastomoses and stomas are not fashioned in DCS. Solid organ injuries management should be similarly directed at achieving haemorrhage control. This may be by removal without attempt at preservation in those organs where this is feasible (such as the spleen and kidney) or by therapeutic packing such as in the liver, where the aim should be to try and reconstitute the hepatic morphology with packs place around the liver, closing any fractures and lacerations to obtain tamponade of the injury. This may also require supplementary suturing to obtain haemostasis, but formal liver resection should not be attempted as part of DCS. In a patient exsanguinating from pelvic trauma pre-peritoneal pelvic packing can be performed to gain control of bleeding. Pre-emptive strategies to prevent compartment syndromes such as fasciotomies and laparostomy are employed. Time in the operating room should be limited and once haemorrhage control and contamination limitation are achieved temporary closure or cover is established to allow the patient to be moved to a critical care environment. Time in stage 2 should be as short as possible; however, taking a patient with active surgical bleeding to the intensive therapy unit (ITU) is futile.
and optimizing perfusion, the acidosis usually corrects and the oxygen debt from anaerobic metabolism is repaid. Coagulopathy is corrected by addressing the hypothermia and acidosis and the administration of fresh frozen plasma, cryoprecipitate and platelets as necessary.2,11 Early return to the operating theatre can be indicated if there is obvious ongoing surgical bleeding or if unaddressed compartment syndromes develop. Stage 4: Return to the operating theatre is dictated by the improvement in the patient’s physiological status. The following indices are used to guide timing to re-operation; a base deficit greater than 4 mmol/litre, lactate of less than 2.5 mmol/litre, core temperature greater than 35 C and an international normalization ratio of less than 1.25 normal. Before the decision to return to the operating theatre is made, plans to assemble the appropriate surgical team must be put in place to ensure that the optimum repairs of the injuries are performed in the optimum surgical environment (right patient, right time, right place, right team). This may require more than one surgical speciality, but with a clearly identified leader to orchestrate the procedures and take a global view of the patient’s condition. At this stage anastomoses are fashioned or stomas raised and vascular repairs performed. Stage 5: Formal closure may not be possible at stage 4 as there may still be significant oedema or clinical risk of developing a compartment syndrome (abdominal or extremity). Therefore a planned further operative phase for closing or covering the site is made.
Stage 3: Critical care stage. In the critical care environment continued attempts at correcting the physiological consequences of the injury and metabolic failure are pursued. These will have started in the preoperative and operative phases. Active rewarming measures with air-warming devices, fluid warmers or arteriovenous warming techniques as well as warm ambient environment are employed. Perfusion is restored to the body tissues. By warming
Developing an integrated ‘DCReDCS’ approach With the developments of DCR, a change in approach is required to integrate resuscitation and surgical phases more closely. This is
Stages of damage control surgery Patient selection complexes C C
C
1. 2. 3. 4. 5.
Major abdominal vascular injury with multiple visceral injuries Multifocal or multicavity exsanguinations with concomitant visceral injuries Multiregional injury with competing priorities
Box 3
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Patient selection Intraoperative stage Critical care stage Return to the operating theatre Formal closure
Box 5
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Ó 2010 Elsevier Ltd. All rights reserved.
EMERGENCY SURGERY
achievable by adopting real-time, point of care technologies to aid rapid diagnosis of conditions such as ATC and to measure the effect of treatment. Thromboelastometry allows early diagnosis of coagulopathies and monitoring of therapy.12 Other near patient tests of acidebase status and electrolyte abnormalities are also available together with other monitoring techniques such as near infra-red spectroscopy (NIRS)13 to measure tissue oxygenation allow near continuous physiological monitoring and tailoring therapeutic approaches to individual casualty responses rather than a ‘one size fits all’ protocol approach. Individual tailoring of treatment options optimizes the therapy for that specific casualty and minimizes the potential risks of unnecessary interventions. It could also conserve resources. This ‘DCReDCS’ approach may lead to early correction of physiological status, which in the classical DCS approach occurred in stage 3 (critical care). Addressing the physiological consequences of trauma, and the coagulopathy in particular, as part of a damage control resuscitation (DCR) strategy from the outset of resuscitation may result in improved physiology intraoperatively; but surgery should not be delayed to achieve this goal, DCR and DCS should occur concurrently from the outset (see Figure 1). Many of these lessons have been learnt on the battlefield, but have potential consequences for civilian trauma management.14 Adopting this ‘DCReDCS’ approach has changed the potential surgical goals with improvement of the patient’s physiological status. Recent reports of this in vascular surgery in a combat support hospital setting have allowed extended operating (median time 4.5 hours) with more definitive revascularization to be undertaken.15 The authors state that “combining these two concepts (DCR & DCS) may allow preservation of limbs that previously would have been amputated for fear of developing or exacerbating the lethal triad of coagulopathy, acidosis and
DCReDCS practice points C
C C C C
C
ATC, acute traumatic coagulopathy; DCR, damage control resuscitation; DCS, damage control surgery.
Box 6
hypothermia.” A further study has shown improved survival with early haemostatic resuscitation used intraoperatively in patients with TIC.5
Conclusion The development in understanding of pathophysiological consequences of injury, and the development of DCR and potential techniques to aid early diagnosis and monitor effects of therapy, has opened the possibility of optimizing the patient’s physiological status in stages 1 and 2 of the classical DCS sequence, that had previously occurred in stage 3. This has led to the ability to tailor therapy individually, and to extend the surgical options. In order to achieve the goal of optimizing outcome DCR and DCS should be considered a single concept (DCReDCS), and requires a fully integrated cross-disciplinary trauma team with joint training and understanding in this approach. Practice points are summarized in Box 6. A
Approaches to DCS and DCR–DCS Classical DCS approach
Resuscitation
CritCare
DCS
REFERENCES 1 Loveland J, Boffard K. Damage control in the abdomen and beyond. Br J Surg 2004; 91: 1095e101. 2 Holcomb J, Jenkins D, Rhee P, et al. Damage control resuscitation: directly addressing the early coagulopathy of trauma. J Trauma 2007; 62: 307e10. 3 Martini WZ, Pusateri AE, Uscilowicz JM, Delgado AV, Holcomb JB. Independent contributions of hypothermia and acidosis to coagulopathy in swine. J Trauma 2005; 58: 1002e9. 4 Brohi K. Diagnosis and management of coagulopathy after major trauma. Br J Surg 2009; 96: 963e4. 5 Duchesne JC, Islam TM, Stuke L, et al. Hemostatic resuscitation during surgery improves survival in patients with traumatic-induced coagulopathy. J Trauma 2009; 67: 33e9. 6 Brohi K, Cohen M, Ganter MT, Matthay MA, Mackersie RC, Pittet JF. Acute traumatic coagulopathy: initiated by hypoperfusion: modulated through the protein C pathway? Ann Surg 2007; 245: 812e8.
Protocolized resuscitation
Integrated approach DCR–DCS
DCR
DCS
Tailored therapy based on results of real-time near patient monitoring of physiological status DCR, damage control resuscitation; DCS, damage control surgery
Figure 1
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Indications for DCReDCS should be recognized early and the approach initiated immediately (certainly prior to starting surgery) ATC should be recognized early DCR is started early DCS is performed concurrently with DCR Real-time monitoring of physiological indices of patient response, including with thromboelastometry, is performed and DCR is directed accordingly DCReDCS is a dynamic integrated approach to the management of the polytrauma patient, it is not ‘bail-out’ surgery, or a technique used in isolation
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7 Brohi K, Cohen M, Davenport R. Acute coagulopathy of trauma: mechanism, identification and effect. Curr Opin Crit Care 2007; 13: 680e5. 8 Nunez TC, Voskrenensky IV, Dossett LA, Shinall R, Dutton WD, Cotton BA. Early prediction of massive transfusion in trauma: simple as ABC (assessment of blood consumption)? J Trauma 2009; 66: 346e52. 9 Watson GA, Sperry JL, Rosengart MR, et al. Fresh frozen plasma is independently associated with a higher risk of multiple organ failure and acute respiratory distress syndrome. J Trauma 2009; 67: 221e30. 10 Dunne JR, Hawksworth JS, Stojadinovic A, et al. Perioperative blood transfusion in combat casualties: a pilot study. J Trauma 2009; 66: S150e6.
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11 Kirkman E, Watts S, Hodgetts T, Mahoney P, Rawlinson S, Midwinter M. A proactive approach to the coagulopathy of trauma: the rational and guidelines for treatment. J R Army Med Corps 2008; 153: 302e6. 12 Rugeri L, Levrat A, David J, et al. Diagnosis of early coagulation abnormalities in trauma patients by rotation thromboelastography. J Thromb Haemost 2006; 5: 289e95. 13 Cohn SM, Nathens AB, Moore FA, et al. Tissue oxygen saturation predicts the development of organ dysfunction during traumatic shock resuscitation. J Trauma 2007; 62: 44e55. 14 Moor P, Rew D, Midwinter MJ, Doughty H. Transfusion for trauma: civilian lessons from the battlefield. Anaesthesia 2009; 64: 469e72. 15 Fox Charles J, Gillespie David L, Cox EDarrin, et al. Damage control resuscitation for vascular surgery in a combat support hospital. J Trauma 2008; 65: 1e9.
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Ó 2010 Elsevier Ltd. All rights reserved.
Trauma resuscitation and damage control surgery
(i) by a US group, as proactive early treatment to address the lethal triad (by rapid reversal of acidosis, prevention of hypothermia and coagulopathy) on admission to combat hospital.2 (ii) by a UK group as a systematic approach to major trauma combining the catastrophic bleeding, airway, breathing and circulation (
C A Fries Mark J Midwinter
Abstract In recent years the envelope of survivability for victims of high-energy polytrauma has been continuously extended, thanks to advances at all levels of trauma care in both civilian and military practice. The concept of damage control surgery has been embraced by surgeons of various specialities as a paradigm within which to manage these patients, many of whom reach trauma centres alive, having sustained injuries which would until recently have been considered unsurvivable. This paper summarizes the development and application of this approach, and details the latest research evidence and development of this technique to include an integrated ‘Damage Control ResuscitationeDamage Control Surgery’ (DCReDCS) protocol. The traditional staged approach to DCS has been superseded by an integrated DCReDCS approach. This has been driven by a greater understanding of the management of the ‘lethal triad’ of trauma and by technological advances enabling real-time monitoring of physiological indices. This approach can extend initial safe operating times, with concomitant improvement in rates of survival and limb salvage.
Keywords Acute traumatic coagulopathy; damage control resuscitation; damage control surgery; massive transfusion protocols
Introduction Damage control surgery (DCS) is an operative strategy that sacrifices the completeness of the immediate surgical repair in order to address the physiological consequences of the combined trauma of the injury and surgery. In the past this has been very much focussed on abdominal trauma and the idea of performing an ‘abbreviated laparotomy’. However the concepts are applicable to injury beyond the abdomen, including the management of wounds, head injuries, maxillofacial trauma and fractures.1 Damage control resuscitation (DCR) is a more recent concept. It has variously been defined as:
Pathophysiology The central observation behind the philosophy of DCS is the adverse effects of the combined triad of hypothermia, acidosis and trauma-induced coagulopathy (TIC) (as a consequence of the hypothermia, acidosis, consumption and dilution of clotting factors) in trauma patients.1,2 Hypothermia leads to a-adrenergic stimulation with vasoconstriction, exacerbating any organ hypoperfusion, which may be already present secondary to hypotension from the injury. This leads to worsening acidosis. Both hypothermia and acidosis may be further exacerbated by aggressive fluid resuscitation, especially with normal saline. Hypothermia and acidosis combined with the consumption, dilution and failure to replace clotting factors lead to a coagulopathy. Even if major surgical
C A Fries MA MB BChir MRCS is Surgeon Lieutenant Commander Royal Navy, Surgical Trainee, University Hospitals Birmingham and Academic Department of Military Surgery & Trauma (ADMST), Birmingham, UK. Conflicts of interest: none declared. Mark J Midwinter BMedSci (Hons) DipAppStats MD FRCS(Eng) FRCS(Gen) is Surgeon Captain Royal Navy and Defence Professor of Surgery; Honorary Professor, School of Medicine, University of Swansea and Academic Department of Military Surgery & Trauma (ADMST), Birmingham, UK. Conflicts of interest: none declared.
SURGERY 28:11
563
Ó 2010 Elsevier Ltd. All rights reserved.
EMERGENCY SURGERY
bleeding is controlled at this stage the patient will continue to bleed form all cut surfaces prolonging the ‘bloody vicious cycle’ of hypothermia, acidosis and coagulopathy. The degree of coagulopathy is known to be underestimated by standard laboratory tests of coagulation. Hypothermia is directly correlated to injury severity and an independent risk factor for mortality, reaching 100% when core temperature is less than 32 C in patients undergoing a laparotomy. However, the contribution of acidosis, hypothermia and the dilution/consumption of clotting factors to the development of coagulopathy has been overstated.3,4 It has been recently recognized that in up to 30% of patients with major traumatic injuries there is an endogenous coagulopathy that is present early before significant fluid resuscitation and appears to be mediated through the activation of the protein C pathway.5,6 This acute traumatic coagulopathy (ATC) is induced by the combination of trauma, shock and tissue hypoperfusion. Patients who have evidence of ATC on admission to the emergency department are more likely to require massive blood transfusion, develop multiorgan failure and have up to fourfold chance of dying.5,7
UK military massive transfusion protocols (MTP) are based on administering units of PRBCs, FFP in a 1:1 ratio and early use of platelets, where an MTP approach is indicated, but quickly switching to being driven by real-time analysis of coagulopathy using thromboelastometry (TEM). TEM is a viscoelastic whole blood assessment of coagulation. Unlike classical coagulation tests such as prothrombin time (PT), international normalized ratio (INR) and activated partial thromboplastin time (APTT), TEM evaluates whole blood including the interaction between the clotting factors and platelets. It is a ‘near patient’ test in which results are expressed both graphically and numerically that allows the clinical staff to evaluate the clotting dynamics of initiation, propagation and amplification of thrombin generation and fibrin formation as well as fibrinolysis. This approach minimizes risk and facilitates the focussed administration of blood products and clotting factors.
Damage control surgery The decision to adopt a damage control approach to surgical intervention in a trauma patient should be reached early, in order to avoid the vicious cycle being entered, rather than employing DCS as a measure of desperation once the consequences outlined above are established; so-called ‘bail-out’ surgery. Physiological measures to define when a DCS approach should be adopted have been suggested (Box 1). Others have included lactate or base deficit, blood transfusion requirement or injury mechanism and complexes. Rotondo and Zonies identified key factors in patient selection under the headings of Conditions, Complexes and Critical Factors (Boxes 2e4). DCS is only applicable to a minority of trauma patients and if used too liberally may be no better or even worse than immediate definitive surgery. However, too strict a definition as to when to adopt the approach, particularly based on laboratory indices, can mean that the adverse physiological consequences are already established. Experience and rapid surgical assessment are key to making a positive, informed decision to adopt a DCS strategy. Classically five stages of DCS are described (Box 5).1
Damage control resuscitation These new insights into pathophysiological changes have influenced the approach to resuscitation. In patients with injury and massive haemorrhage, massive transfusion protocols have developed to counter the dilution and consumption of clotting factors and to addressing the hypothermia and acidosis. This was achieved primarily by transfusing plasma after a certain number of units of packed red blood cells (PRBC), combined with administering fibrinogen and platelets to correct TIC. The early presence of ATC before significant dilution or consumption of clotting factors has occurred, mandates early recognition and treatment. Recognition has been largely based on clinical indicators of injury severity and blood loss. These clinically based predictions perform with only about 80% sensitivity and specificity.8 Standard laboratory tests for coagulopathy are not sensitive for detecting ATC and have a significant lag behind the clinical picture due to the time delay in their performance. Treatment has been based on protocols with a ‘one size fits all’ approach. Use of blood and plasma can be associated with adverse outcomes other than just those potential risks from exposure to disease transmitted by blood products. There is evidence from a prospective multicentre cohort study in trauma patients who survive their initial injury, of fresh frozen plasma (FFP) transfusion being independently associated with multiorgan failure (MOF) and acute respiratory distress syndrome (ARDS).9 Also a pilot study in combat casualties has indicated that allogenic blood transfusion was associated with increased perioperative infection and impaired wound healing.10 However, haemostatic resuscitation during surgery with a high ratio of FFP to PRBC (around 1:1) in patients with TIC improves survival.5 These studies emphasize the requirement to make a rapid diagnosis, so appropriate treatment can be given to patients requiring haemostatic resuscitation and those patients not requiring such intervention are not exposed to the unnecessary risks. With recognition of the cell-based theory of clotting and the central role of the platelet and platelet surface for factor interaction, earlier use of platelets is recognized as important. Indeed current
SURGERY 28:11
Stage 1: Patient selection and decision making described above. This should occur rapidly either immediately preoperatively or within minutes of the start of surgery. Stage 2: Intraoperative stage. Priorities are haemorrhage control, limiting contamination and temporary closure or cover. Haemorrhage control may be achieved by ligation, suture,
Suggested physiological indications for the damage control surgery approach C C C
Systolic blood pressure less than 70 mmHg Core temperature less than 34 C pH less than 7.1
Box 1
564
Ó 2010 Elsevier Ltd. All rights reserved.
EMERGENCY SURGERY
Patient selection conditions C C C C
Patient selection critical factors
High-energy blunt trauma Multiple torso penetration Haemodynamic instability Presenting coagulopathy and/or hypothermia
C C C C
C
Severe metabolic acidosis (pH 7.30) Hypothermia (temperature <35 C) Resuscitation and operative time >90 minutes Coagulopathy as evidenced by the development of non-mechanical bleeding Massive transfusion (>10 units of packed red blood cells)
Box 2 Box 4
tamponade (by packing or balloon), or shunting. Definitive vascular repair by grafting or anastomosis is not considered a DCS procedure. Contamination control is achieved by closure of the ends of the injured hollow viscus. Bowel ends are closed without attempt to regain gastrointestinal continuity, by tapes, staples or suture. The stomach may be similarly dealt with. Less accessible structures such as the duodenum and bile duct may be dealt with by simply placing drainage tubes to control leakage. Anastomoses and stomas are not fashioned in DCS. Solid organ injuries management should be similarly directed at achieving haemorrhage control. This may be by removal without attempt at preservation in those organs where this is feasible (such as the spleen and kidney) or by therapeutic packing such as in the liver, where the aim should be to try and reconstitute the hepatic morphology with packs place around the liver, closing any fractures and lacerations to obtain tamponade of the injury. This may also require supplementary suturing to obtain haemostasis, but formal liver resection should not be attempted as part of DCS. In a patient exsanguinating from pelvic trauma pre-peritoneal pelvic packing can be performed to gain control of bleeding. Pre-emptive strategies to prevent compartment syndromes such as fasciotomies and laparostomy are employed. Time in the operating room should be limited and once haemorrhage control and contamination limitation are achieved temporary closure or cover is established to allow the patient to be moved to a critical care environment. Time in stage 2 should be as short as possible; however, taking a patient with active surgical bleeding to the intensive therapy unit (ITU) is futile.
and optimizing perfusion, the acidosis usually corrects and the oxygen debt from anaerobic metabolism is repaid. Coagulopathy is corrected by addressing the hypothermia and acidosis and the administration of fresh frozen plasma, cryoprecipitate and platelets as necessary.2,11 Early return to the operating theatre can be indicated if there is obvious ongoing surgical bleeding or if unaddressed compartment syndromes develop. Stage 4: Return to the operating theatre is dictated by the improvement in the patient’s physiological status. The following indices are used to guide timing to re-operation; a base deficit greater than 4 mmol/litre, lactate of less than 2.5 mmol/litre, core temperature greater than 35 C and an international normalization ratio of less than 1.25 normal. Before the decision to return to the operating theatre is made, plans to assemble the appropriate surgical team must be put in place to ensure that the optimum repairs of the injuries are performed in the optimum surgical environment (right patient, right time, right place, right team). This may require more than one surgical speciality, but with a clearly identified leader to orchestrate the procedures and take a global view of the patient’s condition. At this stage anastomoses are fashioned or stomas raised and vascular repairs performed. Stage 5: Formal closure may not be possible at stage 4 as there may still be significant oedema or clinical risk of developing a compartment syndrome (abdominal or extremity). Therefore a planned further operative phase for closing or covering the site is made.
Stage 3: Critical care stage. In the critical care environment continued attempts at correcting the physiological consequences of the injury and metabolic failure are pursued. These will have started in the preoperative and operative phases. Active rewarming measures with air-warming devices, fluid warmers or arteriovenous warming techniques as well as warm ambient environment are employed. Perfusion is restored to the body tissues. By warming
Developing an integrated ‘DCReDCS’ approach With the developments of DCR, a change in approach is required to integrate resuscitation and surgical phases more closely. This is
Stages of damage control surgery Patient selection complexes C C
C
1. 2. 3. 4. 5.
Major abdominal vascular injury with multiple visceral injuries Multifocal or multicavity exsanguinations with concomitant visceral injuries Multiregional injury with competing priorities
Box 3
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Patient selection Intraoperative stage Critical care stage Return to the operating theatre Formal closure
Box 5
565
Ó 2010 Elsevier Ltd. All rights reserved.
EMERGENCY SURGERY
achievable by adopting real-time, point of care technologies to aid rapid diagnosis of conditions such as ATC and to measure the effect of treatment. Thromboelastometry allows early diagnosis of coagulopathies and monitoring of therapy.12 Other near patient tests of acidebase status and electrolyte abnormalities are also available together with other monitoring techniques such as near infra-red spectroscopy (NIRS)13 to measure tissue oxygenation allow near continuous physiological monitoring and tailoring therapeutic approaches to individual casualty responses rather than a ‘one size fits all’ protocol approach. Individual tailoring of treatment options optimizes the therapy for that specific casualty and minimizes the potential risks of unnecessary interventions. It could also conserve resources. This ‘DCReDCS’ approach may lead to early correction of physiological status, which in the classical DCS approach occurred in stage 3 (critical care). Addressing the physiological consequences of trauma, and the coagulopathy in particular, as part of a damage control resuscitation (DCR) strategy from the outset of resuscitation may result in improved physiology intraoperatively; but surgery should not be delayed to achieve this goal, DCR and DCS should occur concurrently from the outset (see Figure 1). Many of these lessons have been learnt on the battlefield, but have potential consequences for civilian trauma management.14 Adopting this ‘DCReDCS’ approach has changed the potential surgical goals with improvement of the patient’s physiological status. Recent reports of this in vascular surgery in a combat support hospital setting have allowed extended operating (median time 4.5 hours) with more definitive revascularization to be undertaken.15 The authors state that “combining these two concepts (DCR & DCS) may allow preservation of limbs that previously would have been amputated for fear of developing or exacerbating the lethal triad of coagulopathy, acidosis and
DCReDCS practice points C
C C C C
C
ATC, acute traumatic coagulopathy; DCR, damage control resuscitation; DCS, damage control surgery.
Box 6
hypothermia.” A further study has shown improved survival with early haemostatic resuscitation used intraoperatively in patients with TIC.5
Conclusion The development in understanding of pathophysiological consequences of injury, and the development of DCR and potential techniques to aid early diagnosis and monitor effects of therapy, has opened the possibility of optimizing the patient’s physiological status in stages 1 and 2 of the classical DCS sequence, that had previously occurred in stage 3. This has led to the ability to tailor therapy individually, and to extend the surgical options. In order to achieve the goal of optimizing outcome DCR and DCS should be considered a single concept (DCReDCS), and requires a fully integrated cross-disciplinary trauma team with joint training and understanding in this approach. Practice points are summarized in Box 6. A
Approaches to DCS and DCR–DCS Classical DCS approach
Resuscitation
CritCare
DCS
REFERENCES 1 Loveland J, Boffard K. Damage control in the abdomen and beyond. Br J Surg 2004; 91: 1095e101. 2 Holcomb J, Jenkins D, Rhee P, et al. Damage control resuscitation: directly addressing the early coagulopathy of trauma. J Trauma 2007; 62: 307e10. 3 Martini WZ, Pusateri AE, Uscilowicz JM, Delgado AV, Holcomb JB. Independent contributions of hypothermia and acidosis to coagulopathy in swine. J Trauma 2005; 58: 1002e9. 4 Brohi K. Diagnosis and management of coagulopathy after major trauma. Br J Surg 2009; 96: 963e4. 5 Duchesne JC, Islam TM, Stuke L, et al. Hemostatic resuscitation during surgery improves survival in patients with traumatic-induced coagulopathy. J Trauma 2009; 67: 33e9. 6 Brohi K, Cohen M, Ganter MT, Matthay MA, Mackersie RC, Pittet JF. Acute traumatic coagulopathy: initiated by hypoperfusion: modulated through the protein C pathway? Ann Surg 2007; 245: 812e8.
Protocolized resuscitation
Integrated approach DCR–DCS
DCR
DCS
Tailored therapy based on results of real-time near patient monitoring of physiological status DCR, damage control resuscitation; DCS, damage control surgery
Figure 1
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Indications for DCReDCS should be recognized early and the approach initiated immediately (certainly prior to starting surgery) ATC should be recognized early DCR is started early DCS is performed concurrently with DCR Real-time monitoring of physiological indices of patient response, including with thromboelastometry, is performed and DCR is directed accordingly DCReDCS is a dynamic integrated approach to the management of the polytrauma patient, it is not ‘bail-out’ surgery, or a technique used in isolation
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7 Brohi K, Cohen M, Davenport R. Acute coagulopathy of trauma: mechanism, identification and effect. Curr Opin Crit Care 2007; 13: 680e5. 8 Nunez TC, Voskrenensky IV, Dossett LA, Shinall R, Dutton WD, Cotton BA. Early prediction of massive transfusion in trauma: simple as ABC (assessment of blood consumption)? J Trauma 2009; 66: 346e52. 9 Watson GA, Sperry JL, Rosengart MR, et al. Fresh frozen plasma is independently associated with a higher risk of multiple organ failure and acute respiratory distress syndrome. J Trauma 2009; 67: 221e30. 10 Dunne JR, Hawksworth JS, Stojadinovic A, et al. Perioperative blood transfusion in combat casualties: a pilot study. J Trauma 2009; 66: S150e6.
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11 Kirkman E, Watts S, Hodgetts T, Mahoney P, Rawlinson S, Midwinter M. A proactive approach to the coagulopathy of trauma: the rational and guidelines for treatment. J R Army Med Corps 2008; 153: 302e6. 12 Rugeri L, Levrat A, David J, et al. Diagnosis of early coagulation abnormalities in trauma patients by rotation thromboelastography. J Thromb Haemost 2006; 5: 289e95. 13 Cohn SM, Nathens AB, Moore FA, et al. Tissue oxygen saturation predicts the development of organ dysfunction during traumatic shock resuscitation. J Trauma 2007; 62: 44e55. 14 Moor P, Rew D, Midwinter MJ, Doughty H. Transfusion for trauma: civilian lessons from the battlefield. Anaesthesia 2009; 64: 469e72. 15 Fox Charles J, Gillespie David L, Cox EDarrin, et al. Damage control resuscitation for vascular surgery in a combat support hospital. J Trauma 2008; 65: 1e9.
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