Damage control resuscitation in patients with severe traumatic hemorrhage. Eamon raith 2, aprof william m griggs 3 mbbs, mba, pgdipavmed, fanzca, fcicm, facap, faicd, am, asm introduction damage control resuscitation dcr is a systematic approach to major exsanguinating trauma that. Initial laparotomy, intensive care unit icu resuscitation, and definitive reconstruction. Principles of damage control resuscitation dr kav senasinghe cme march 2016, scgh ed 2. Dcr involves haemostatic resuscitation, permissive hypotension where appropriate and damage control surgery. Damage control surgery dcs is a strategy originally described in the context of exsanguinating abdominal trauma, where the completeness of operative repair is sacrificed in order to limit physiologic deterioration. Pdf damage control resuscitation for patients with major. Joint theater trauma system clinical practice guideline. No more than two units of untyped plasma should be administered under these conditions.
Khan s, allard s, weaver a, barber c, davenport r, brohi k. We describe a rare case of thoracoabdominal impalement successfully managed based on the concept of. Damage control surgery and continued resuscitation. Haemostatic resuscitation massive transfusion protocol 3. The sequential strategy of operation followed by resuscitation has been replaced by an integrated approach so that resuscitation and surgery are undertaken simultaneously, with close communication and cooperation between surgeon and anaesthetist.
We hypothesize a survival advantage in dcl patients managed with dcr when compared with dcl patients managed with conventional resuscitation efforts cre. A practice management guideline from the eastern association for the surgery of trauma. Thor is a multidisciplinary group of clinical, translational and basic investigators with a common interest in improving outcomes and safety in patients. Manual occlusion of the aorta at the diaphragmatic hiatus can be performed. The leading cause of death among trauma patients remains uncontrolled hemorrhage and accounts for approximately 3040% of traumarelated deaths. The following goes through the different phases to illustrate, step by step, how one might approach this. Identification and treatment of lifethreatening hemorrhage. Damage control resuscitation dcr is a strategy that seeks to prevent or mitigate hypothermia, acidosis, and coagulopathy through combined treatment paradigms. Damage control resuscitation journal of intensive care biomed. Coagulopathy observed in trauma patients was thought to be a resuscitation associated phenomenon.
Damage control resuscitation for the special forces medic. He recommended temporizing patients with abdominal packing and temporary closure to allow restoration of normal physiology prior to returning to the operating room. It currently includes early blood product transfusion, immediate arrest andor temporization of. Damage control resuscitation in patients with severe. Abdominal damage control surgery and reconstruction. Damage control laparotomy was first described by dr. The aim is to keep the patient alive whilst avoiding interventions and situations that risk worsening their situation by driving the lethal triad of hypothermia, coagulopathy and acidosis or excessively stimulating the immuneinflammatory system. Although the largest human study cited by the authors suggested some benefit from a dcr strategy, there were. The 8th edition of the atls manual was changed to reflect developing.
Damage control resuscitation dcr for trauma, initially described to address the entire lethal triad hypothermia, acidosis and coagulopathy immediately upon admission to a combat hospital before damage control surgery dcs, is now accepted as part of an integrated approach dcrdcs from point of wounding to definitive treatment. Damage control resuscitation of the exsanguinating trauma patient. A number of risk factors for massive transfusion upon hospital admission have been identified. Identification and treatment of lifethreatening hemorrhage by philip c. Trauma hemostasis and oxygenation research network thor. Damage control resuscitation dcr is a strategy for resuscitating patients from hemorrhagic shock to rapidly restore homeostasis. Damage control surgery and damage control resuscitation.
Professor and vice chair director, center for translational injury research university of texas health sciences center houston. Coagulopathy observed in trauma patients was thought to be a resuscitationassociated phenomenon. Part one 15 this article is the first of two meant to provide an approach to critical care using damage control resuscitation dcr as a guideline adapted for our use. Damage control resuscitation as a structured intervention begins immediately after rapid initial assessment in the ed and progresses through the or into the icu. The trauma hemostasis and oxygenation research thor network held its third annual remote damage control resuscitation rdcr symposium in june of 20 at solstrand hotel, near bergen norway. Damage control resuscitation comprises early hemorrhage control, hypotensive resuscitation permissive hypotension, hemostatic resuscitation. Advances in trauma resuscitation, an issue of emergency medicine clinics of north america authors. The replacement of lost and consumed coagulation factors was the mainstay in the resuscitation of hemorrhagic shock for many decades. Ultrasound of the chest and abdomen in patients with penetrating trauma to chest, abdomen, or pelvis or.
New transfusion practice, new survivors, new directions. Damage control resuscitation 1 damage control resuscitation. Abc paradigm with a series of clinical techniques from. A controlled resuscitation strategy is feasible and safe in hypotensive trauma patients. Evidence for damage control resuscitation is lacking the bmj. In the beginning, damage control surgery was described by the three main steps.
Abstract the role of the anesthesiologist in the damage control approach to the patient is of utmost importance and can have a profound impact on the patients ultimate outcome. The aim is to keep the patient alive whilst avoiding interventions and. Factor viia for correction of traumatic coagulopathy. Damage control surgery dcs is a concept of abbreviated laparotomy, designed to prioritize shortterm physiological recovery over anatomical reconstruction in the seriously injured and compromised patient. Damage control resuscitation is associated with a reduction in resuscitation volumes and improvement in survival in 390 damage control laparotomy patients. The case for early use of blood products and hypertonic saline in exsanguinating trauma victims graeme a. Thor position paper on remote damage control resuscitation. Damage control surgery in the era of damage control.
Simplifying and improving prolonged trauma care 15 this article is the first of two meant to provide an approach to critical care using damage control resuscitation dcr as a guideline adapted for our use. All efforts are directed toward this goal by repeated point of care testing and the use of multiple blood products and drugs readily available in theater, albeit in new ratios and amounts. Damage control has been adapted to truncating initial surgical procedures on severely injured patients to provide only interventions necessary to control hemorrhage and contamination to focus on reestablishing a survivable physiologic status. Damage control surgery in the era of damage control resuscitation. Addresses the resuscitation of patients with lifethreatening hemorrhage in prehospital settings. Damage control resuscitation dcr is a systematic approach to the management of the trauma patient with severe injuries that starts in the emergency room and continues through the operating room and the intensive care unit icu. Focuses on both civilian and military applications of dcr. Traumatic injury is the leading cause of death in under 45s most victims are young males most preventable deaths are due to haemorrhage leading preventable cause of death in. Damage control resuscitation of the exsanguinating trauma. Damage control resuscitation aims to limit blood loss and prevent coagulopathy by combining hypotensive resuscitation, early airway control, and.
Damage control surgery dcs is a technique of surgery used to care for critically ill patients. Pdf the early recognition and management of hemorrhage shock are among the most difficult tasks challenging the clinician during primary. Much of the evidence for permissive hypotension has been extrapolated from animal studies. Harlan stone in 1983 when he suggested that patients with severe trauma should have their primary procedures abbreviated when coagulopathy was encountered. Damage control resuscitation army medical center of excellence. This study is a 4year retrospective study of all dcl. Jtts clinical practice guidelines for damage control resuscitation at level iib and iii infuse 250 cc plasma iv or io after the rfviia. Addition of a prehospital initial evaluation stage ground zero and separation of definitive. Austere resuscitative and surgical care arsc cpg id. Apr 03, 2014 damage control resuscitation definition. Twenty years ago, damage control surgery dcs was implemented to challenge the coagulopathy of trauma. Joint theater trauma system clinical practice guideline guideline onlynot a substitute for clinical judgment august 2011 page 2 of 25 damage control resuscitation at level iibiii treatment facilities b.
Damage control resuscitation combines two seemingly. Damage control surgery an overview sciencedirect topics. Damage control resuscitation dcr is defined as a systematic approach to major trauma, combining a. It has been stated that surgery does not follow resuscitation, it. Restrictive fluid resuscitation in combination with damage control resuscitation.
It currently includes early blood product transfusion, immediate arrest andor temporization of ongoing hemorrhage i. Damage control resuscitation dcr is a bundle of care first described by holcomb. Damage control resuscitation describes an approach to the early care of very seriously injured patients. While typically trauma surgeons are heavily involved in treating such patients, the concept has evolved to other subspecialty services. Tdcr focuses on counteracting the lethal triad coagulopathy, acidosis, and hypothermia, primarily through the use of blood products and. Andy fisher and his damage control resuscitation for prolonged field care cpg. His method involved joining an artery in the donor directly to a vein in the recipient. Masterdamage control resuscitationhetzlergodbeeboysen. Mike brzozowski discuss the latest in trauma controversies. Tdcr is the active medical management of a patient in hemorrhagic shock in the combat environment. A systematic approach to major exsanguinating trauma incorporating several strategies to decrease mortality and morbidity. Damage control resuscitation in combination with damage. Damage control resuscitation and surgery is the concept of controlled hypotension, haemostatic resuscitation and abbreviated surgical procedures following severe trauma.
The anesthesiologist is vital in overseeing the process of. Efforts are focused on blood product transfusion with whole blood. Browne, capt mc fs usn based on a presentation at the 2011 aaps annual scientific meeting, tysons corner, va, june 2122. Joint theater trauma system clinical practice guideline guideline onlynot a substitute for clinical judgment feb 20 page 1 of 32 damage control resuscitation at level iibiii treatment facilities damage control resuscitation at level iibiii treatment facilities original releaseapproval. This is a guideline truly written for the medic working despite lack of help or resources in an austere environment continue reading podcast episode 47. Each of these phases has defined timing and objectives to ensure best outcomes. Damagecontrol resuscitation for the special forces medic. Jtts clinical practice guidelines for damage control resuscitation at level iib and iii dutton rp, mccunn m, hyder m, dangelo m, oconnor j, hess jr, scalea tm.
Select multiple pdf files and merge them in seconds. Dcr is a current and proven practice and provides aggressive. Damage control resuscitation for patients with major trauma. Damage control resuscitation is not a separate level of care, but completely integrated. Damage control surgery can be divided into the following three phases. Damage control2 damage control resuscitation introduction understanding that hemorrhage is associated with coagulopathy and can be worsened by aggressive fluid resuscitation, the military instituted a standard of care instituting permissive hypotension, minimization of crystalloids, and early use of blood products to stabilize wartime casualties.