Damage Control Resuscitation: Directly Addressing the Early Coagulopathy of Trauma

USAISR, Fort Sam Houston, TX 78234-6315, USA.
The Journal of trauma (Impact Factor: 2.96). 03/2007; 62(2):307-10. DOI: 10.1097/TA.0b013e3180324124
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    • "However, over use of crystalloids can result in third spacing worsening bowel edema, anastomotic leaks, ACS and multi-organ failure [59,60]. Accordingly, the use of massive transfusion protocols (MTP) has been recommended for DCL patients [60-62]. MTP’s advocate using blood transfusion earlier in resuscitation, using blood and blood products instead of crystalloid or colloid, and the infusion of red cells, plasma, and platelets in a 1:1:1 ratio. "
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    ABSTRACT: Damage control laparotomy was first described by Dr. Harlan Stone in 1983 when he suggested that patients with severe trauma should have their primary procedures abbreviated when coagulopathy was encountered. He recommended temporizing patients with abdominal packing and temporary closure to allow restoration of normal physiology prior to returning to the operating room for definitive repair. The term damage control in the trauma setting was coined by Rotondo et al., in 1993. Studies in subsequent years have validated this technique by demonstrating decreased mortality and immediate post-operative complications. The indications for damage control laparotomy have evolved to encompass abdominal compartment syndrome, abdominal sepsis, vascular and acute care surgery cases. The perioperative critical care provided to these patients, including sedation, paralysis, nutrition, and fluid management strategies may improve closure rates and recovery. In the rare cases of inability to primarily close the abdomen, there are a number of reconstructive strategies that may be used in the acute and chronic phases of abdominal closure.
    Full-text · Article · Dec 2013 · World Journal of Emergency Surgery
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    • "Only 3% of patients with severe blunt trauma present with hemorrhagic shock; however, they have a high mortality rate of about 60% (19). Tolerating permissive hypotension and resuscitating the patient with red blood cells and plasma allows for an earlier correction of the coagulation cascade (20). This in turn limits the amount of crystalloids; therefore, decreasing the effects of swelling on all organ systems. "
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    ABSTRACT: The decision to stop or continue resuscitation in a patient with blunt trauma and cardiac arrest arriving pulseless to the hospital has always been controversial. While many authors still believe that it is a futile effort, with no chance of success for complete neurological recovery, some recent reports have challenged the idea. Here we report complete recovery of a severely injured patient following a motor vehicle accident who lost vital signs completely before arrival at our trauma center. No cardiac motion was detected on ultrasound examination on arrival. Emergency department thoracotomy, open cardiac massage, massive blood transfusion, damage control laparotomy with abdominal and pelvic packing, followed by angio-embolization of pelvic bleeding, and staged abdominal exploration were performed. This case is an example showing that resuscitation of patients with blunt trauma and cardiac arrest arriving pulseless to the hospital is not always futile.
    Full-text · Article · Dec 2013
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    • "Of the risk factors, higher OIS grade worsens the outcome significantly and unfortunately the severity grade could not be changed when the injuries occurred. However, coagulopathy with prolonged initial PT, APTT and decreased platelet count could be corrected, but it needs early transfusion of fresh frozen plasma (FFP) and platelet as damage control resuscitation (DCR) in major trauma [6] [14] [20]. DCR consists of two parts and is initiated within minutes of arrival in the ED. "
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    ABSTRACT: This retrospective study aimed to assess the clinical experience and outcome of damage control laparotomy with perihepatic packing in the management of blunt major liver injuries. From January 1998 to December 2006, 58 patients of blunt major liver injury, American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) equal or greater than III, were operated with perihepatic packing at our institute. Demographic data, intra-operative findings, operative procedures, adjunctive managements and outcome were reviewed. To determine whether there was statistical difference between the survivor and non-survivor groups, data were compared by using Mann-Whitney U test for continuous variables, either Pearson's chi-square test or with Yates continuity correction for contingency tables, and results were considered statistically significant if p<0.05. Of the 58 patients, 20 (35%) were classified as AAST-OIS grade III, 24 (41%) as grade IV, and 14 (24%) as grade V. At laparotomy, depending on the severity of injuries, all 58 patients underwent various liver-related procedures and perihepatic packing. The more frequent liver-related procedures included debridement hepatectomy (n=21), hepatorrhaphy (n=19), selective hepatic artery ligation (n=11) and 7 patients required post-laparotomy hepatic transarterial embolization. Of the 58 patients, 28 survived and 30 died with a 52% mortality rate. Of the 30 deaths, uncontrolled liver bleeding in 24-h caused 25 deaths and delayed sepsis caused residual 5 deaths. The mortality rate versus OIS was grade III: 30% (6/20), grade IV: 54% (13/24), and grade V: 79% (11/14), respectively. On univariate analysis, the significant predictors of mortality were OIS grade (p=0.019), prolonged initial prothrombin time (PT) (p=0.004), active partial thromboplastin time (APTT) (p<0.0001) and decreased platelet count (p=0.005). The mortality rate of surgical blunt major liver injuries remains high even with perihepatic packing. Since prolonged initial PT, APTT and decreased platelet count were associated with high risk of mortality, we advocate combination of damage control resuscitation with damage control laparotomy in these major liver injuries.
    Full-text · Article · Sep 2013 · Injury
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