“Damage control resuscitation” as applied to the management of the major trauma patient integrates permissive hypotension, haemostatic resuscitation and damage control surgery.
Outline the key principles of each of these three strategies, including the rationale.
a. Permissive hypotension
b. Haemostatic resuscitation
c. Damage control surgery
“Damage control resuscitation” as applied to the management of the major trauma patient integrates permissive hypotension, haemostatic resuscitation and damage control surgery.
Outline the key principles of each of these three strategies, including the rationale.
a. Permissive hypotension
1. Keep SBP low enough to avoid exsanguination but high enough to maintain perfusion.
2. Relates to disruption of an unstable clot by higher pressures and worsening of bleeding.
b. Haemostatic resuscitation
i. Correct hypothermia
1. Decreases platelet responsiveness.
2. Increases platelet sequestration in liver and spleen
3. Reduces Factor function eg Factors XI and XII
4. Alters fibrinolysis
ii. Correct acidosis
1. pH strongly effects activity of Factors V, VIIa and X.
2. Acidosis inhibits thrombin generation
3. Cardiovascular effects of acidosis (pH <7.2) – decreased contractility and CO, vasodilatation and hypotension, bradycardia and increased dysrhythmias.
iii. Treat coagulopathy early and aggressively
1. Many coagulopathic changes occur early after trauma, therefore need to correct early.
2. Use much higher FFP to PRBC ratios (1:1/2:3) than previously used. Is associated with improved survival.
3. Higher platelet to PRBC transfusion ratios also becoming more popular but evidence is less clear.
4. Cryoprecipitate provides an additional option for Factor replacement for a lower volume of fluid.
5. rFVIIa has been used in trauma, but off label and anecdotally.
iv. The use of blood products instead of isotonic crystalloid fluid aiming for limited volume replacement
1. Large volume crystalloids can lead to dilutional coagulopathy and exacerbate bleeding.
2. Crystalloids have no O2 carrying capacity and do little to correct the anaerobic metabolism and O2 debt associated with shock.
3. Need less volume of blood product therefore likely to be less tissue and organ (eg lung, small intestine mucosa) oedema and failure (eg pulmonary oedema, abdominal compartment syndrome)
4. Hypertonic saline is another option (proven restored microvascular flow, decreased tissue oedema, attenuated inflammatory response).
c. Damage control surgery
1. Management of the metabolic derangement of ongoing bleeding supersedes the need for definitive surgery
2. Abbreviated operations that control haemorrhage and contain spillage from the alimentary and urogenital tracts.
3. Rapid transfer to ICU for correction of acidosis, coagulopathy and hypothermia
4. Definitive operation is deferred.
5. These operations tend to have a high complication rate
6. Survival is given preference over morbidity.
Definition:
Rationale:
Key principles:
Definition:
Rationale:
Key principles:
An excellent article on this is available from 2004 (Critical Care Clinics)
Definition:
Rationale:
Key principles:
Morrison, C. Anne, et al. "Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock: preliminary results of a randomized controlled trial." Journal of Trauma and Acute Care Surgery 70.3 (2011): 652-663.
Kaafarani, H. M. A., and G. C. Velmahos. "Damage Control Resuscitation In Trauma." Scandinavian Journal of Surgery (2014): 1457496914524388.
Jaunoo, S. S., and D. P. Harji. "Damage control surgery." International Journal of Surgery 7.2 (2009): 110-113.
Schreiber, Martin A. "Damage control surgery." Critical care clinics 20.1 (2004): 101-118.