The The Fourth Fourth Mediterranean Mediterranean Emergency Emergency Medicine Medicine Congress Congress Sorrento 1519 September 2007 Sorrento 15 15-19 September 2007
Damage Control Surgery
Francesco Enrichens MD FACS Chief Department of Surgery CTO Hospital Turin Turin,, Italy Chief EMS Regione Piemonte
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Damage Control Surgery
The background Piemonte Region: 4,4 milions people 8 Dispatch centers 2 millions calls/year 423.728 EMS runs/year Torino area: 2,2 milioni people 1 Dispatch center About 1 millions calls/year 217.453 EMS runs/year
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Damage Control Surgery
Hospital Hospitaland andEMS EMSnetwork networkMay May2006 2006 Medical Medical facilities facilities (DEA) (DEA) 41 41
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Damage Control Surgery
Year 2006
EMS runs 423.728
24% 24%
Other
12% 12%
Cardiovascular G.U.
1% 1%
TRAUMA
Poisonong Malignancy
26%
2% 2% 2% 2% 10% 10%
Neurological Not identified Behavioral Respiratory Trauma
8% 8%
3% 3%
12% 12%
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Damage Control Surgery
118 EMS Pts. Severity 11,5% score
CODE 0
75,1%
CODE 1
11,6%
CODE 2
1,6%
CODE 3
0,2%
CODE 4
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Damage Control Surgery
DEANET EVOLUTION
IMAGING IMAGING TRANSMISSION TRANSMISSION
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Damage Control Surgery
System IT development Head trauma
AMI/CVA
Burns
Strokes
Trauma
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Damage Control Surgery
INTERHOSPITAL NETWORK Consulting activity & Transfer to treatment
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Damage Control Surgery
Socio -economic sustainability: some Socio-economic relevant results SINCE 1997: 1. 1. more more 8459 8459 cons. cons. completed completed 2. 2. 80% 80% of of transport transport avoided avoided 3. 3. 57% 57% of of pts. pts. transferred transferred underwent underwent surgery surgery 4. 4. more more 250.000 250.000 images images handled handled 5. 5. 26% 26% pts pts treated treated at at home home without without hospitalization hospitalization
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Damage Control Surgery
Analysis Years: 2003 – 2004 – 2005 - 2006 EMS runs 118: 1.598.419 Year mean: 399.605 Day mean: 1.095 Trauma: Trauma year mean: Trauma day mean:
383.540 95.885 263
24%
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Damage Control Surgery
"Trauma ” on the road Regione Piemonte "Trauma”
cod. 4 cod. 3 2006 2005 2004 2003
cod. 2 cod. 1 cod. 0 0
10000
20000
30000
40000
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Damage Control Surgery
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Damage Control Surgery
Ospedale CTO Trauma Center
Spine unit and rehab
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Damage Control Surgery
Number of trauma per year
100000 95000 90000 85000
0 20
0 20
0 20
0 20
0 20
2
3
4
5
6
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Damage Control Surgery
Hip fractures on total trauma patients:
-17,34%
Pelvic fractures on total trauma patients:
+21,54%
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Damage Control Surgery
January-December 2006 Severe trauma ISS = or > 16 o 324 patients
o 239 male o 85 female o Mean age 46 o Admitted to ICU 70%
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Damage Control Surgery Damage control is the term used in the Merchant Marine, maritime industry and Navies for the emergency control of situations that may hazard the sinking of the ship
..Simple measures may stop flooding…
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Damage Control Surgery
• Conventional surgical treatment ER
OR
Death
It’s better to cure in more • “Damage Control” treatment phases than to kill in one ER Time
OR
ICU
OR
ICU
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Damage Control Surgery
Hypothermia
Lethal triad
Death Acidosis
Coagulopathy
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Damage Control Surgery
A mathematical model predicts a heat loss rate during a trauma laparotomy of 4,6 ° C per hour A core temp below 32° C during trauma laparotomy in considered universally fatal Despite global warming
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Damage Control Surgery
Concepts: 1. 2. 3. 4.
Rapid laparotomy Bleeding control Spillage control Temporary abdominal closure (avoiding tension)
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Damage Control Surgery Patients likely to need damage control surgery Thoracic trauma • Penetrating injury and SBP < 90 mmHg • Pericardial fluid on FAST • Emergency room thoracotomy Abdominal and pelvic trauma • Penetrating injury and SBP < 90 mmHg • Blunt trauma and peritoneal fluid on FAST and SBP < 90 mmHg • Closed pelvic fracture and peritoneal fluid on FAST and SBP < 90 mmHg or gross blood on DPL • Open pelvic fracture
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Damage Control Surgery Patients likely to need damage control surgery Extremity trauma • Shotgun wound to femoral triangle • Mangled extremity General trauma • Emergency laparotomy to be followed by emergent craniotomy or emergent thoracotomy or emergent angiographic embolization of fracture associated pelvic bleeders
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Damage Control Surgery
Abdominal trauma: Hemodynamically normal
NOM
Hemodynamically unstable
Laparotomy Angiography
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Damage Control Surgery
Hemodynamic instability FAST NEG Pelvis stable
FAST NEG Pelvis unstable
FAST POS Pelvis stable
FAST POS Pelvis unstable
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Damage Control Surgery
Hemodynamic instability FAST POS Pelvis unstable
Damage Control Surgery
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Damage Control Surgery
Surgery vs non operative management is a surgical decision and must be made by a surgeon
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Damage Control Surgery AAST -OIS LIVER GRA D E I H e m a to m a : su b c a ps u lar < 10% su rf ac e a rea. L a c e ra tion: c a psu lar te ar, < 1 c m p a re nc h y ma l de p th . GRA D E II H em atom a: subcapsular 10-50% sur fa ce area. Int raparenchim al < 1 0 cm dia m eter L acerati on: 1-3 cm parenchy m al depth, < 10 cm l ength. GRA D E III H em atom a: subcapsular > 50% surf ace area or ex pandi ng, rup tur ed sucapsul ar or i nt r apar enchy m al hem ato ma. Int raparenchym al hema toma > 10 cm or ex pandi ng. L acerati on: > 3 c m parenc hy m al depth, > 10 cm l ength. GRA D E IV L acerati on: par ench ym al disr uption i nvo l vi ng 25 - 75% of hepati c l obe or 1 -3 C oui naud’s segm ents in a sin gl e lo be. GRA D E V L acerati on: par ench ym al disr uption i nvo l vi ng > 75% of h epatic l obe or > 3 Co ui naud’s segm ents i n a si ngl e l obe. Vas cul ar: Jux tahepati c v enous in j uri es i e. r etr ohepati c v ena cava, m aj or hepatic ve ins.
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Damage Control Surgery
Liver trauma: Grade I and II often found during laparotomy for other indications (ruptured spleen) Definitive treatment (no touch, DTC, Argon beam coagulation, topic haemostatics, suture)
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Damage Control Surgery
Liver trauma: Grade III, IV and V definitive treatment or damage control Resectional debridment, perihepatic packing, baloon tamponade, Foley catheter tamponade
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Damage Control Surgery
Liver trauma years 1990-2007 • Total 242 patients • From January 1990 to March 1998 79 patients • From April 1998 to July 2007 163 patients
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Damage Control Surgery
Liver trauma years 2004-2007 • 85 patients • Low grade (I and II) 47 patients • High grade (III, IV and V) 38 patients • Operated 29 • Non operated 56
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Damage Control Surgery
Liver Trauma: 1990-1998 Surgery
NOM Failure
68
11
M/F
56/12
6/5
Age
34
43
ISS
40
34
RTS
4.9
6.9
N° pts
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Damage Control Surgery
Liver trauma: 1998-2007 Surgery
NOM
64
99
M/F
50/14
72/27
Age
35.8
39.6
ISS
42.3
23.7
RTS
4.91
6.89
N° pts
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Damage Control Surgery
Liver trauma: grading and surgical procedure I
II
III
No touch
12
13
4
DTC Haemostatics
5
8
3
2
15
25
19
Suture
IV
V 3
Limited resection
3 3
Major resection
3
8
Resectional debridment
1
6
4
Liver packing
2
6
6
Caval or portal suture Total
6 17
36
35
36
33
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Damage Control Surgery
Liver trauma: grading and NOM (years 2004-2007) Grade
2004-2005
2005-2007
Total
I
1
2
3
II
8
13
21
III
12
11
23
IV
3
4
7
V
0
0
0
Total
24
30
54
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Damage Control Surgery
Liver trauma: NOM of 99 patients Failure
Success
16 (16.2%)
83 (83.8%)
M/F
12/4
60/23
Age
48.2
35.7
ISS
35.58
19.28
RTS
6.2
7.1
N° pts
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Damage Control Surgery
Liver trauma: surgical procedure 1990-1998 Surgery
NOM Failure
No touch
11
3
DTC Haemostatics
3
Suture
32
Limited resection
2
Major resection
9
Resectional debridment
4
Liver packing
2
Caval or portal suture
5
6
2
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Damage Control Surgery
Liver trauma: surgical procedure 1998-2007 Surgery
NOM Failure
No touch
16
4
DTC Haemostatics
11
4
Suture
16
8
Limited resection
1
Major resection
2
Resectional debridment
5
Liver packing
12
Caval or portal suture
1
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Damage Control Surgery
Liver trauma: Hospital stay 1990-1998
1998-2007
Surgery
NOM failure
Surgery
NOM
23 days
35 days
31 days
23 days
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Damage Control Surgery Liver trauma: hospital stay and associated lesions
50 45 FRATTURA DI BACINO
Giorni di degenza
40 35
FRATTURA DI FEMORE
30
FR. TIBIA E/O PERONE
25
LESIONI SNC LESIONI SPLENICHE EMOTORACE PNX
20 15
LESIONI SNC
10
FR. TIBIA E/O PERONE 5
FRATTURA DI FEMORE
0
FRATTURA DI BACINO LESIONE LESIONE ASSOCIATA ASSOCIATA PRESENTE ASSENTE
PNX EMOTORACE LESIONI SPLENICHE
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Damage Control Surgery
Liver trauma: Mortality Surgery Years
NOM
Total
1990-2007 1998-2007 1990-2007
Number
67/143
3/99
70/242
Percentage
46.8%
3.0%
28.9%
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Damage Control Surgery Liver trauma: grading and cause of death Grade Death
%
Cause of death Shock
CNS
Both
Other
1
1
1
5
1
I
3/25
12
II
11/67
16
3
2
III
13/72
18
5
6
IV
18/47
38
11
1
2
4
V
25/31
81
21
1
3
7
1
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Damage Control Surgery
O.I. S live r I.O. O.I. S. liver TC ISS RTS Blood pressur e Heart rate Hb Creatinin Run time to hospital INR Ph art erial GCS Age Hemoperitone um (ml)
Dead 3,8 ± 1,2 1,9 ± 1,4 46,6 ± 11 ,2 3,7 ± 2,1 57,1 ± 51 ,2 93,1 ± 42 ,8 9,9 ± 3,0 1,2 ± 0,3 52,8 ± 38 ,2 1,9 ± 1,1 7,2 ± 0,2 6,2 ± 4,6 38,2 ± 18 ,8 2673 ,3 ± 1385,0
Survived 2,7 ± 1,2 2,3 ± 1,1 29,3 ± 13 ,3 6,7 ±1,6 110,7 ± 2 5,8 100,1 ± 2 3,0 11,6 ± 2,3 1,1 ± 0,3 60,0 ± 76 ,9 1,4 ± 0,4 7,3 ± 0,1 12,3 ± 3,9 33,1 ± 14 ,6 1306 ,9 ± 1216,6
p value 1,03 X 10 -6 0,22 3,65 X 10 -15 1,6 X 10 -15 1,64 X 10 -10 0,151 0,00032 0,0214 0,25 0,00053 0,037 4,38 X 10 -13 0,04 4,21 X 10 -9
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Damage Control Surgery
Liver trauma: mortality and surgical procedure
Mortalità %
100 90
NO TOUCH
80 70
DEBRIDEMENT - DTC - AGENTI EMOSTATICI EPATORRAFIA
60
RESEZIONE ATIPICA
50
RESEZIONE ANATOMICA MAGGIORE RESEZIONE ANATOMICA LIMITATA LIVER PACKING
40 30 20
SUTURA VENA CAVA E/O VENE PORTA
10 0 1
Intervento eseguito
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Damage Control Surgery
Liver trauma: AST/ALT value and injury grade
600 500
U.I./L
400 AST
300
ALT 200 100 0 GRADO 1
GRADO 2
GRADO 3
GRADO 4
GRADO 5
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Damage Control Surgery AB 17 years old female. Hit during a karate competition Hemodynamically normal.
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Damage Control Surgery AB: Non Operative Management. CT scan at 30 days
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Damage Control Surgery
Conclusions: •Non Operative Management hemodynamically normal irrespective of the grade of lesions
in all patients
•Damage Control Surgery in hemodinamically abnormal patients, mostly in high grade lesions or in patients with a heavy burden of injury
In trauma surgery simple things work
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Damage Control Surgery
Thank You for your attention
