Episode 32: Damage Control Resuscitation

Author: Eoghan Colgan @eoghan_colgan
Special Guest: Pete Davis

01/05/19

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Guest Bios

Lt Col. Pete Davis

Pete Davis is a Consultant in Emergency Medicine in the Defence Medical Services (Royal Army Medical Corps), based at the Queen Elizabeth University Hospital here in Glasgow.

He has a background in prehospital and wilderness medicine, highlights of which include: retrieval work in New Zealand, a fellowship with HEMS London, and helping to pioneer both the Emergency Medical Retrieval Service in Scotland and the military forward aeromedical evacuation system that operated during the Afghanistan conflict ("MERT").

Successfully mixing both business and pleasure, he has climbed or skied throughout the world during many years of expeditions.

Show Notes

Eoghan discusses Damage Control Resuscitation with Pete Davis, a Consultant in Emergency Medicine and Prehospital Medicine, and an Army Medic who has served in multiple conflicts around the world. Find out what this concept is and how to apply it to your sickest trauma patients.

Take Home Points

What is Damage Control Resuscitation?

A targeted strategy for resuscitation
- aimed at a small group of trauma patients who have entered the lethal triad of trauma:
  - Acidaemia (PH≤7.2
  - Coagulopathy
  - Hypothermia (<35 degrees)
- They are on the cusp of life and have no physiological reserve left
- These cases demand rapid and aggressive resuscitation summarised by:
  - minimising and controlling ongoing blood loss
  - restoring circulating blood volume
  - optimising oxygenation
  - maximising tissue perfusion
SURVIVAL TRUMPS MORBIDITY and managing the metabolic derangement caused by trauma trumps definitive care/surgery in the first instance.

Controlling external haemorrhage

Simple Measures:
- Splinting extremities
- Elevating limbs
- large ‘blast’ bandages to compress wounds
Tourniquets - returning in favour
- use when simple measures (above) fail to control the haemorrhage
- principles:
  - place the tourniquet as distally on the limb as possible so that it controls the bleeding but preserves as much proximal tissue as possible
  - keep on for as little time as possible
  - when arrive at ED - can exchange windless tourniquet for a pneumatic tourniquet
    - this is an opportunity for limb surgeon to assess the level of haemorrhage
Novel Haemostatic Agents
- impregnated with chemicals that promote coagulation
- applied onto or packed into the wound
- typically granules or impregnated ribbon-gauze
- Examples include:
  - Quick Clot
  - Haemcon
  - Celox
- They provide an exothermic reaction which can be toxic to skin/tissue which may require further debridement later
- They are especially useful in in areas where compression is difficulty to apply
  - Junctional areas such as:
    - the root of the neck
    - Axilla
    - groin
- Basics of applying:
  - quick trauma bandage over wound whilst preparing equipment/dressing
  - assistant then removes this bandage whilst team-member packs the wound rapidly with haemostatic dressing (right up to surface)
  - then 1-2 trauma bandages over that for further external compression
- These are temporising measures and will require surgical/vascular control

Airway and Breathing

Advanced airway techniques, mechanical ventilation and decompression helps to optimise oxygenation and tissue perfusion which is vital to survival

Fluid Resuscitation

Avoid crystalloids if at all possible - use cautiously if no other option available
Start haemostat resuscitation early (on the field if possible) - this consists of:
- tranexamic acid
- packed red cells
- in some cases FFP (freeze-dried often pre-hospitally)
  - give in a 1:1 ratio with packed red cells
The decision on how much fluids to give is estimated based on:
- an assessment of the mechanism of injury
- evidence of major haemorrhage or ongoing bleeding
- measurable physiological parameters such as oxygenation, heart rate and systolic blood pressure
Some pre-hospital services have warning devices such as:
- Enflow system
- Belmont Buddy Lite

Scoop-and-run or stay-and-play

If you have a medical team:
- you can deliver advanced medical procedures in the field
- but you should still be mindful of scene-time and minimise it to around 30-45 minutes
- some of the advanced procedures can still be delivered during the transfer phase
Non-medical teams will be restricted mainly to external haemorrhage control procedures
- do these then transfer quickly to receiving hospital

FINALLY

remember to keep the patient warm!

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Hannah BellMay 1, 20192 Comments