1. 3.1
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2. Management of Surgical Emergencies Part 1 : Critical Care
Damage Control in Emergency Surgery
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3. Damage Control Developed in military surgery
Damage control resuscitation
Damage control surgery for trauma
Laparotomy
Orthopaedic
Neurosurgery
Damage control surgery for sepsis
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4. Lethal Triad Coagulopathy Hypothermia Metabolic Acidosis
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5. 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)
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6. Hypothermia Loss of blood Vasoconstriction
Decreased tissue perfusion and metabolism
Exposure
Resuscitation with cold fluids
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7. Metabolic Acidosis Why? Reduced tissue oxygenation
Anaerobic metabolism
Lactic acid accumulation
Resuscitation with Saline & PRC
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8. 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)
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9. 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.
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10. 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 hours.
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11. 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
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12. 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.
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13. 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
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14. DCS 6: Complex injuries Duodenum Pancreas Porta hepatis Oesophagus
Pelvis
IVC and Aorta
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15. 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
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16. Questions?
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17. 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).
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