Damage control resuscitation as a structured intervention begins immediately after rapid initial assessment in the ed and progresses through the or into the icu. While typically trauma surgeons are heavily involved in treating such patients, the concept has evolved to other subspecialty services. Khan s, allard s, weaver a, barber c, davenport r, brohi k. Each of these phases has defined timing and objectives to ensure best outcomes. It currently includes early blood product transfusion, immediate arrest andor temporization of. Damage control surgery and continued resuscitation. 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. 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. 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 resuscitation dcr is a bundle of care first described by holcomb.
Identification and treatment of lifethreatening hemorrhage by philip c. It has been stated that surgery does not follow resuscitation, it. Although damage control surgery and resuscitation was initially described following abdominal injury, the basic principle has been extended to all aspects of trauma care. Browne, capt mc fs usn based on a presentation at the 2011 aaps annual scientific meeting, tysons corner, va, june 2122. Initial laparotomy, intensive care unit icu resuscitation, and definitive reconstruction. Coagulopathy observed in trauma patients was thought to be a resuscitation associated phenomenon. The case for early use of blood products and hypertonic saline in exsanguinating trauma victims graeme a. Damage control resuscitation combines two seemingly. The aim is to keep the patient alive whilst avoiding interventions and. Damage control surgery an overview sciencedirect topics. Twenty years ago, damage control surgery dcs was implemented to challenge the coagulopathy of trauma. Damage control resuscitation of the exsanguinating trauma patient. 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. 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.
A controlled resuscitation strategy is feasible and safe in hypotensive trauma patients. Damage control resuscitation and surgery is the concept of controlled hypotension, haemostatic resuscitation and abbreviated surgical procedures following severe trauma. The 8th edition of the atls manual was changed to reflect developing. Andy fisher and his damage control resuscitation for prolonged field care cpg. A number of risk factors for massive transfusion upon hospital admission have been identified. Abc paradigm with a series of clinical techniques from. Damage control resuscitation comprises early hemorrhage control, hypotensive resuscitation permissive hypotension, hemostatic resuscitation. Austere resuscitative and surgical care arsc cpg id.
Damage control resuscitation in patients with severe. Ppt damage control resuscitation powerpoint presentation. Damage control resuscitation in patients with severe traumatic hemorrhage. Damage control resuscitation describes an approach to the early care of very seriously injured patients. Factor viia for correction of traumatic coagulopathy. Identification and treatment of lifethreatening hemorrhage.
Manual occlusion of the aorta at the diaphragmatic hiatus can be performed. 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. We hypothesize a survival advantage in dcl patients managed with dcr when compared with dcl patients managed with conventional resuscitation efforts cre. 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. Pdf damage control resuscitation for patients with major. 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. Damage control laparotomy was first described by dr. Damage control surgery dcs is a technique of surgery used to care for critically ill patients. Trauma resuscitation hemorrhage the most common cause of preventable death in trauma optimal fluid resuscitation regimen debate is on more recently damage control resuscitation dcr has received more attention permissive hypotension aka controlled resuscitation is part of a broader strategy dcr. Pdf the early recognition and management of hemorrhage shock are among the most difficult tasks challenging the clinician during primary. It has been stated that surgery does not follow resuscitation, it is part of resuscitation 9 and dcs. He recommended temporizing patients with abdominal packing and temporary closure to allow restoration of normal physiology prior to returning to the operating room.
Haemostatic resuscitation massive transfusion protocol 3. Masterdamage control resuscitationhetzlergodbeeboysen. No more than two units of untyped plasma should be administered under these conditions. This study is a 4year retrospective study of all dcl.
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. 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. These temporized patients would then undergo continued resuscitation and aggressive correction of. In the beginning, damage control surgery was described by the three main steps. Damage control resuscitation dcr is defined as a systematic approach to major trauma, combining a. Advances in trauma resuscitation, an issue of emergency medicine clinics of north america authors. The following goes through the different phases to illustrate, step by step, how one might approach this. 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. Coagulopathy observed in trauma patients was thought to be a resuscitationassociated phenomenon.
Damage control resuscitation dcr is a strategy that seeks to prevent or mitigate hypothermia, acidosis, and coagulopathy through combined treatment paradigms. Damage control resuscitation is not a separate level of care, but completely integrated. Damage control resuscitation journal of intensive care biomed. Damage control resuscitation dcr is a strategy for resuscitating patients from hemorrhagic shock to rapidly restore homeostasis. Dcr involves haemostatic resuscitation, permissive hypotension where appropriate and damage control surgery. 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. Thor is a multidisciplinary group of clinical, translational and basic investigators with a common interest in improving outcomes and safety in patients. 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. Damage control resuscitation 1 damage control resuscitation. Efforts are focused on blood product transfusion with whole blood. A systematic approach to major exsanguinating trauma incorporating several strategies to decrease mortality and morbidity.
Principles of damage control resuscitation dr kav senasinghe cme march 2016, scgh ed 2. Harlan stone in 1983 when he suggested that patients with severe trauma should have their primary procedures abbreviated when coagulopathy was encountered. Damage control surgery can be divided into the following three phases. Much of the evidence for permissive hypotension has been extrapolated from animal studies. Apr 03, 2014 damage control resuscitation definition. Abdominal damage control surgery and reconstruction. 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. New transfusion practice, new survivors, new directions. Damage control resuscitation is a resuscitation modality that integrates permissive hypotension, hemostatic resuscitation, and damage control surgery, initially addressing all three components of the lethal triad. Select multiple pdf files and merge them in seconds.
Although the largest human study cited by the authors suggested some benefit from a dcr strategy, there were. Pdf damage control resuscitation for patients with major trauma. Damagecontrol resuscitation for the special forces medic. Duke md, guidry c, guice j, stuke l, marr ab, hunt jp, meade p, mcswain ne jr, duchesne jc. Tdcr is the active medical management of a patient in hemorrhagic shock in the combat environment. Trauma hemostasis and oxygenation research network thor. Damage control surgery and damage control resuscitation.
Joint theater trauma system clinical practice guideline. Damage control surgery in the era of damage control resuscitation. Ultrasound of the chest and abdomen in patients with penetrating trauma to chest, abdomen, or pelvis or. 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. 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. Evidence for damage control resuscitation is lacking the bmj. The leading cause of death among trauma patients remains uncontrolled hemorrhage and accounts for approximately 3040% of traumarelated deaths. Mike brzozowski discuss the latest in trauma controversies. It currently includes early blood product transfusion, immediate arrest andor temporization of ongoing hemorrhage i. Dcr is a current and proven practice and provides aggressive. Patient care must focus on rapid triage, initial resuscitation with blood products, rapid control of hemorrhage and contamination with a damage control approach, and subsequent transfer to higher echelon. Damage control resuscitation of the exsanguinating trauma. Damage control resuscitation is associated with a reduction in resuscitation volumes and improvement in survival in 390 damage control laparotomy patients. Damage control resuscitation in combination with damage.
The replacement of lost and consumed coagulation factors was the mainstay in the resuscitation of hemorrhagic shock for many decades. In part 1 they give us some key pearls and pitfalls on traumaairway management, the value of the cspine collar, how to clear the cspine, vascular access options in trauma, damage control rescuscitation, the best resuscitation fluids to use including. 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. Damage control resuscitation aims to limit blood loss and prevent coagulopathy by combining hypotensive resuscitation, early airway control, and. Damage control resuscitation for patients with major trauma. Jtts clinical practice guidelines for damage control resuscitation at level iib and iii infuse 250 cc plasma iv or io after the rfviia. Thor position paper on remote damage control resuscitation. 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 surgery in the era of damage control. Damage control surgery dcs is a wellestablished concept and consists of an initial timelimited operation to save life th e or icaly sn 1 u, p d f m resuscitation on the intensive care unit, then further definitive surgery. What if the patient is not responding to resuscitation efforts. Focuses on both civilian and military applications of dcr. His method involved joining an artery in the donor directly to a vein in the recipient. Damage control resuscitation army medical center of excellence.
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