Damage Control Resuscitation

Damage Control
Resuscitation
H M Cassimjee
Critical Care Specialist
Department of Critical Care & Level 1 Trauma Unit
Inkosi Albert Luthuli Central Hospital

Damage Control
Resuscitation
only for
“DAMAGED PATIENTS”

Damage Control Resuscitation
• Hypotensive Resuscitation
• „Haemostatic‟ Resuscitation
+ Aggressive Warming
• Damage Control Surgery

Epidemiology
David S. Kauvar, MD, Rolf Lefering, PhD, and Charles E. Wade, PhD. Impact of Hemorrhage on Trauma Outcome:
An Overview of Epidemiology, Clinical Presentations, and Therapeutic Considerations. J Trauma.
2006;60:S3–S11.

Epidemiology
Exanguination :
commonest cause of
DOA
David S. Kauvar, MD, Rolf Lefering, PhD, and Charles E. Wade, PhD. Impact of Hemorrhage on Trauma Outcome:
An Overview of Epidemiology, Clinical Presentations, and Therapeutic Considerations. J Trauma.
2006;60:S3–S11.

31% Mortality for Direct Admissions
2 / 3 DEAD WITHIN 12 HRS
ISS 41
S Afr Med J 2011;101:176-178.

Epidemiology
Sauaia, Angela MD; Moore, Frederick A. MD; Moore, Ernest E. MD et al .
Epidemiology of Trauma Deaths: A Reassessment. J Trauma :38(2), February 1995, pp 185-193

Epidemiology
Heckbert, S R Outcome after Hemorrhagic Shock in Trauma Patients. J Trauma 45(3) 1998, pp 545-549

Epidemiology
8 % of Trauma pts Transfused
3 % of all Trauma pts
± 75% of BLOOD USE
John J. Como, Richard P. Dutton, Thomas M. Scalea. Blood transfusion rates in the care of acute trauma. TRANSFUSION
2004;44:809-813.

Uncontrolled coagulopathic hemorrhage is now the
major cause of potentially preventable death
following trauma.
Hess J R. Editorial. Damage control resuscitation: the need for specific blood products to treat the coagulopathy of trauma.
Volume 46, May 2006 TRANSFUSION 685

“Hemorrhage, which produces such terror in the
bystanders . . . . Should never unnerve the
surgeon, who requires all of his self
possession . . . To cope successfully with
this ebbing away of life.”
J.J. Chisolm, Surgeon General, Confederate States of America
Chisolm JJ: A Manual of Military Surgery, for the Use of Surgeons in the Confederate States Army; with an Appendix of the Ruies and Regulations of
the Medical Department of the Confederate States, p 127. Richmond. VA, West & Johnson. 1861.

Ann. Surg. VOl. 197(5):532-535

The innovation of “Damage Control”:
• Once coagulopathy noted:
– Operation immediately aborted
– Abdominal tamponade effected „Closure under tension‟
– Reexploration when pts blood adequately clotted
Ann. Surg. VOl. 197(5):532-535

93%
MORTALITY RATE
35%
Ann. Surg. VOl. 197(5):532-535

Ann. Surg. VOl. 197(5):532-535

Predicting Mortality
• The “Bloody vicious cycle”:
• Injurity severity score > 25
• pH < 7.10 + systolic blood pressure < 70
• Core temperature < 34°c
When all 3 present: incidence of coagulopathy = 98%
Cosgriff N, Moore E, Sauaia A et al. Predicting Life-threathening Coagulopathy in the Massively transfused Trauma
Patient: Hypothermia and Acidosis Revisited. J Trauma 42(5) 1997. 857-862

The Deadly Triad
hypothermia
acidosis
coagulopathy

“Bloody Vicious Cycle”
Bleeding
Resuscitation
Coagulopathy
Acidosis
Hypothermia

“Bloody Vicious Cycle”
Bleeding
Depletion
Resuscitation
Coagulopathy
Acidosis
Hypothermia

“Bloody Vicious Cycle”
Bleeding
Resuscitation
Coagulopathy
Depletion
Dilution
Acidosis
Hypothermia

“Bloody Vicious Cycle”
Bleeding
Resuscitation
Coagulopathy
Depletion
Dilution
Dysfunction
Acidosis
Hypothermia

Bleeding
Resuscitation
Coagulopathy
Depletion
Dilution
Dysfunction
Acidosis
Hypothermia

Bleeding
Resuscitation
Coagulopathy
Depletion
Dilution
Dysfunction
Acidosis
Hypothermia

J Trauma. 2003;54:1127–1130.

24.4% coagulopathy on admission
Base Deficit > 6
J Trauma. 2003;54:1127–1130.

John R. Hess, Allison L. Lindell, Lynn G. Stansbury, Richard P. Dutton, and Thomas M. Scalea. TRANSFUSION
2009;49:34-39.

Coagulopathy of Trauma
SHOCK / HYPOPERFUSION
Thrombomodulin
Activation of Protein C

Coagulopathy of Trauma
endothelium
TM
APC
THROMBIN
tPA
tPA
tPA
tPA
tPA
tPA
tPA
tPA
tPA
tPA
tPA
tPA
PAI-1
PA
I-1

Fibrinolysis
TRAUMA
Coagulation

•General consensus:
•Early use of RBC + plasma + platelets offers
best chance of limiting coagulopathy

1 : 1 : 1

Dutton RP. Shock Management. Trauma Anaesthesia. Ed Smith CE, Como JJ. Cambridge University press

J Trauma. 2007;63:805–813.

Time to death
2 Hrs
Time to Death
4 Hrs
38 Hrs
Haemorrhage Mortality
Rates
92.5% 78 % 37 %
J Trauma. 2007;63:805–813.

Studies recommending higher plasma : RBC ratios
Stahel PF et al. Transfusion strategies in postinjury coagulopathy. Curr Opin Anaesthesiol. 2009;22:289-298

J Trauma. 2009;66:358–364.

J Trauma. 2010;69: 46–52

J Trauma. 2010;69: 46–52

24 hrs
Heckbert, S R Outcome after Hemorrhagic Shock in Trauma Patients. J Trauma 45(3) 1998, pp 545-549

“Avoid fluids that don’t clot or
carry oxygen !!”
…… R Dutton EMCRIT webcast

J Trauma. 2002;52:1141–1146.
J Trauma. 2011;70: 652–663

Hypotensive Resuscitation
With judicious fluid administration – not
vasoactive agent use
• Difficult to keep blood pressure at
hypotensive threshold
• “Hypotensive” pts did no worse
• “Hypotensive” pts bled less

Trauma Outcomes
• Avoid fluids that don
ART
Or
SYSTEM

50u BLOOD in 48hrs
Cinat, M. E. et al. Arch Surg 1999;134:964-968.

REPLICATE THIS !!
NOT AN EXERCISE IN FUTILITY !!
69% survival !
P. Hakala et al. Injury, Int. J. Care Injured 30 (1999) 619±622

NOT AN EXERCISE IN FUTILITY !!
HIGHEST PRBC TRANSFUSION
DOCUMENTED IN A SURVIVOR

NOT AN EXERCISE IN FUTILITY !!
HIGHEST PRBC TRANSFUSION
DOCUMENTED IN A SURVIVOR
167 UNITS
> 150 UNITS IN 1 ST 15 HOURS

Damage Control Resuscitation
The Damage that really matters

The enemy within
“DAMAGED” PATIENTS
DAMPs
Damage Associated Molecular Patterns

Vargas-Parada, L. (2010) Mitochondria and the Immune Response. Nature Education 3(9):15

FASEB J. 17, 993–1002 (2003)
Time also matters

Damage Control Resuscitation
• Rapid identification:
• “smashed / damaged”
• ABG & INR on admission
• ROTEM / TEG

Damage Control Resuscitation
• Rapid identification
• Haemostatic resuscitation:
• Hypotensive resuscitation
• Aggressive re-warming – every drop of fluid
through an in-line warmer
• 1:1:1 if significant blood transfusion considered

Damage Control Resuscitation
• Rapid identification
• Haemostatic resuscitation
• Damage Control Surgery:
• Theatre ASAP: 10 – 15 minutes

BLOOD IS THICKER THAN WATER

Trends in Immunology April 2011, Vol. 32, No. 4