Damage Control Resuscitation

Damage Control Resuscitation

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Damage Control Resuscitation:
The New Face of Damage Control

J. trauma Volume 69(4), October 2010, pp 976-990

“Damage control” for severely injured patients to provide only interventions necessary to control hemorrhage and contamination to focus on reestablishing a survivable physiologic status.

Topics include DCR: surgery, transfusion ratios, permissive hypotension, recombinant factor VIIa (rFVIIa), hypertonic fluid solutions, and the lethal triad of hypothermia, acidosis, and coagulopathy.

PERMISSIVE HYPOTENSION

Keep the blood pressure low enough to avoid exsanguination while maintaining perfusion of end organs.
Trauma patients without definitive hemorrhage control should have a limited increase in blood pressure until definitive surgical control of bleeding can be achieved.

ISOTONIC CRYSTALLOIDS

• dilutional coagulopathy
• hypothermia
• hyperchloremic acidosis 

HYPERTONIC SALINE

HTS attractive for its ability to raise blood pressure quickly at much lower volumes of infusion than isotonic fluids and, thus, potentially easier to use and transport into combat.

Risks and concerns associated with HSD:

• Uncontrolled bleeding
• Hyperchloremic acidosis
• Central pontine myelinolysis

COMPONENTS OF COAGULOPATHY

 1. Hypothermia

ER: resuscitation period
OR: exposure of the peritoneum

2.  Acidosis
3.  Coagulopathy: More than 5 units of pRBC will lead to a dilutional coagulopathy

Early Identification of Shock

• altered mental status, cool/clammy skin, and an absent radial pulse 

• shock index (SI= HR/SBP)

• bicarbonate, base deficit, and lactate

• ABC (assessment of blood consumption) scoring:

1. Penetrating mechanism
2. Positive FAST
3. SBP ≦ 90 mmHg on arrival
4. Heart rate ≧120 bpm on arrival

Score ≧ 2 is 75% sensitive and 86% specific for predicting massive transfusion

A Blood- and Coagulation Factor-Based Resuscitation Strategy

The optimal ratio of FFP to PRBC was 1:1 and that this should be given early in the course.

Resuscitation With Blood

Fresh whole blood transfusion is currently primarily limited to the most severely injured military combat casualties.

Recombinant Factor VIIA

• for all trauma: off-label use!
• rFVIIa seems to be safe and possibly decreases transfusion in blunt trauma.
• rFVIIa has not shown any efficacy in penetrating trauma.

DAMAGE CONTROL SURGERY

Three Phase:

1. Initial operation with hemostasis and packing
2. Transport to the ICU to correct the conditions of hypothermia, acidosis, and coagulopathy
3. Return to the OR for definitive repair of all temporized injuries