3.1 Copyright UKCS #284661815

Management of Surgical Emergencies Part 1 : Critical Care Damage Control in Emergency Surgery Copyright UKCS #284661815

Damage Control Developed in military surgery Damage control resuscitation Damage control surgery for trauma Laparotomy Orthopaedic Neurosurgery Damage control surgery for sepsis Copyright UKCS #284661815

Lethal Triad Coagulopathy Hypothermia Metabolic Acidosis Copyright UKCS #284661815

Coagulopathy 1 Early trauma induced coagulopathy Up to 25% of traumas Occurs immediately 2 Secondary Continuing losses Dilution with crystalloids Tissue hypo-perfusion  acidosis and hypothermia (Coagulation is enzymatic process - cooling alters enzyme function) Copyright UKCS #284661815

Hypothermia Loss of blood Vasoconstriction Decreased tissue perfusion and metabolism Exposure Resuscitation with cold fluids Copyright UKCS #284661815

Metabolic Acidosis Why? Reduced tissue oxygenation Anaerobic metabolism Lactic acid accumulation Resuscitation with Saline & PRC Copyright UKCS #284661815

DL Resuscitation for Rapid Blood Loss: Management principles Avoid Lethal Triad Haemostatic resuscitation 1:1:1 Tranexamic Acid???? Hypotensive resuscitation = permissive hypotension (keep systolic <90 mmHg or to keep radial pulse palpable and cerebration intact) Copyright UKCS #284661815

Damage Control Surgery for abdominal trauma: STEPS: Laparotomy: Four quadrant packing Clamp rapid bleeding Shunts for major arterial injuries Staple or tie off or drain intestinal injuries Leave abdomen open Maximum 90 minutes from emergency room to ICU. Copyright UKCS #284661815

DCS 2: In ICU: Back for definitive surgery after 12-24 hours. Warm patient up Correct coagulopathy Wait for acidosis to reverse Further DCR with blood products 1:1:1 Back for definitive surgery after 12-24 hours. Copyright UKCS #284661815

DCS 3: Orthopaedic surgery: Pelvis: stabilise with exoskeleton or tie up Long bones: Guillotine amputations Rapid exoskeleton Back slab K-wires across the knee and vascular shunts Copyright UKCS #284661815

DCS 4: Neurosurgery For head injuries in association with other major injuries where neurosurgery can have major impact on outcome: Subdural Extradural Burr holes and evacuate clot. Copyright UKCS #284661815

DCS 5: Cardio-thoracic injury Penetrating cardiac injury: Thoracotomy/sternotomy Incise pericardium Evacuate clot Staple knife wound with skin stapler. Severe lung injury: Thoracotomy Clamp lung hilum with soft bowel clamp Staple or ligate lobe Copyright UKCS #284661815

DCS 6: Complex injuries Duodenum Pancreas Porta hepatis Oesophagus Pelvis IVC and Aorta Copyright UKCS #284661815

Damage Control Laparotomy for Sepsis e.g. Perforated diverticulitis; Multiple bowel perforations with typhoid or lymphoma (after steroids): Drain Copious wash-out Tie off small bowel or ileostomy Colostomy Copyright UKCS #284661815

Questions? Copyright UKCS #284661815

Summary Do not be afraid to do minimum surgery to keep patient alive and to come back later. Teamwork and good communication essential (with anaesthetists, ICU, theatre staff, blood bank, labs, family). Copyright UKCS #284661815