Episode 33: Damage Control Resuscitation Part 2
Author: Eoghan Colgan @eoghan_colgan
Special Guest: Pete Davis
22/05/19
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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
Emergency room Priorities
Ongoing resuscitation
Need to differentiate patients injuries
Create a management plan based on defined or predicted injuries
Ongoing resuscitation (CABCDE approach)
Ongoing haemorrhage
Could exchange tourniquet for a pneumatic tourniquet
Do this in presence of a surgeon ideally who can assess the injury and plan a surgical strategy
If AB not secured – emergency anaesthetic and ventilation, with chest decompression (formal chest drains) if required
Blood product resuscitation
If no machines available:
Fluid resuscitation:
Balanced haemostatic resuscitation
Ratios vary between centres
Military practice : RBC, FFP + Platelets in 1:1:1 ratio
Practically speaking:
Start with what’s immediately available
Typically O negative blood or O positive for men or women of non-childbearing age
Also universal donor fresh frozen plasma should be available
When full cross-match is done then achieve balanced ratio when other products are available
There is no place for crystalloid in a balanced haemostatic resuscitation
Machines that guide haemostatic resuscitation
Thromboelastography (TEG) (see below)
Rotational Thromboelastomotery (RoTEM)
Takes a blood sample and allows it to clot then subjects it to stress
Gives a graphical representation of the quality of the clot that has been formed by the patient
Users have to interpret it, but it helps guide when to give more of one or other products
How much blood product to give:
Choosing endpoint for haemostatic resuscitation is not an exact science – will be based on:
Physiological parameters such as heart rate and systolic blood pressure (aiming for around 100mmHg) and urine output
Serial arterial blood gases – is the acidaemia correcting
Ongoing coagulopathy with repeated RoTEM measurements
Whole Blood
Ideally we would replace like for like
But there are technical difficulties around storing blood
And risk of transmission of BBV’s
There is experience of this in the military and is very effective
But needs to be collected from a pre-screened donor panel
Storage is probably around 48 hours maximally
Dried Blood Products
Freeze-dried Plasma has grown in popularity due to its ease of storage, transport and reconstitution in the field
Permissive hypotension
Concept came about through the management of ballistic type injuries
The idea that accepting subnormal blood pressures will stop the disruption of the patients first attempts to clot the injuries (avoid ‘popping the clot’)
The use of permissive hypotension is limited to the management of penetrating torso or abdominal trauma, with the expectation that there will be emergency surgical vascular control imminently
There is no place for permissive hypotension in blunt trauma
Controlling Internal Haemorrhage
If unable to externally control haemorrhage then the requirement is surgical intervention
There are some temporising measures that can be used in the ED, for example:
REBOA – Retrograde Endovascular Balloon Occlusion of the Aorta
A balloon catheter is inserted through one of the femoral arteries, and balloon fed upo to the descending aorta where it can be inflated to temporarily restrict blood flow to distal damaged blood vessels
It’s the endovascular equivalent of cross-clamping the aorta
Damage Control Surgery
Some trauma patients are on the cusp of life and have entered the lethal triad of trauma.
The crux of the matter is they do not have the physiological reserve to undergo a long definitive operative procedure
Damage Control Surgery has one of two purposes:
To arrest ongoing bleeding
To minimise contamination if the bowel or urogenital tract has been breached
The right time for dame control surgery:
Evidence of ongoing bleeding and persistent hypothermia, acidaemia and coagulopathy
It then needs to be done as rapidly as possible
Maximum time they should be on the operating table is around 40 minutes
Surgeon does the minimum to preserve healthy tissue and remove devitalised tissue, and remove any contamination
No attempt made to close the abdominal wall to avoid abdominal compartment syndrome (cover with a clear dressing)
When to CT?
CT is excellent at defining the extent of the injuries but gaining emergency vascular control may trump CT
This would be an opportunity to control bleeding and restore circulating volume (whilst also treating coagulopathy)
Can then go to CT to define the extent of injuries and plan more definitive care
Abdominal Compartment Syndrome
A massive systemic inflammatory response to the injury itself
SIRS is then multiplied by operating on the patient
The bowel can then become really oedematous and if this occurs in an enclosed space, it can lead to bowel ischaemia
Intensive Care – Phase 4
Patients can go to ICU from ED with or without damage control surgery
Principles are:
Restore normal physiology as much as possible
Ongoing correction of the lethal triad of trauma
Optimising ventilation, tissue perfusion and oxygenation
Take-Home Pearl:
To be an effective team-leader you need to focus on the human factors
When to be ascertive and when to be a good listener/follower.
Links
Thromboelastography (TEG) click image for more information
Rotational Thromboelastometry (RoTEM) click image for more information