damage control in trauma by brohi

DAMAGE CONTROL RESUSCITATION

Centre for Trauma SciencesQueen Mary University of Londonwww.c4ts.qmul.ac.uk

Royal London Major Trauma CentreBarts Health NHS Trust

KARIM BROHI, FRCS FRCAProfessor of Trauma Sciences, QMUL

National Trauma Haemorrhage Mortality Rates

43%

0

10

20

30

40

50

60

70

ISS > 15 ISS > 24Injury Severity Score

Mo

rta

lity

(%

)

RLHMSHCH

*

*

Comparative Mortality

Damage Control Resuscitation

Damage Control Resuscitation

MAINTAIN HAEMOSTATICCOMPETENCE

Damage Control Resuscitation

1. Early haemorrhage control (DCS)2. Permissive hypotension3. Limit fluid infusions (dilution)4. Target coagulopathy

Damage Control Resuscitation

1. Early haemorrhage control (DCS)2. Permissive hypotension3. Limit fluid infusions (dilution)4. Target coagulopathy

Trauma patients are more likely to die from intra-operative metabolic failure than from a failure to complete operative repairs.

Trauma patients are more likely to die from intra-operative metabolic failure than from a failure to complete operative repairs.

Haemorrhage Control

Trauma patients are more likely to die from intra-operative metabolic failure than from a failure to complete operative repairs.

Haemorrhage ControlManage Sepsis

Protect from further injury

Trauma patients are more likely to die from intra-operative metabolic failure than from a failure to complete operative repairs.

Restoration of Physiology(ICU)

What is it really?

FAILURE:

FAILURE: to maintain homeostasis

FAILURE: to protect cells, tissues & organs

FAILURE: to preserve endothelial integrity

What’s bad about DCS?

Damage Control Resuscitation

1. Early haemorrhage control (DCS)2. Permissive hypotension3. Limit fluid infusions (dilution)4. Target coagulopathy

Damage Control Resuscitation

1. Early haemorrhage control (DCS)2. Permissive hypotension3. Limit fluid infusions (dilution)4. Target coagulopathy

Trauma

Hemorrhage

Shock

ATC

TRAUMA-INDUCED COAGULOPATHY (TIC)

Trauma

Hemorrhage

Genetics

Shock

Fibrinolysis Inflammation Hypothermia Acidemia

Loss, Dilution

ATC

TRAUMA-INDUCED COAGULOPATHY (TIC)

750 ml crystalloid

1U PRBC

750 ml crystalloid

4U PRBC2 FFP

4500 ml crystalloid500 colloid8U PRBC7U FFP1 PLT, 2 CRYO

7500 ml crystalloid1000 colloid12U PRBC8U FFP1 PLT, 2 CRYO

0.3 0.4 0.5 0.6 0.7 0.8 0.9

30

40

50

60

70

80

Center Mean FFP:RBC

Pe

rce

nt S

urv

ivin

g

AB

BC

FF

GH

HI

IJ

LM

MM

OP

PP

QQ

ST

VX

WWWX

XY

p = 0.05R2 = 0.19

34 ISS 4427 ISS 3422 ISS 27

*

*

0

10

20

30

40

50

60

70

ISS > 15 ISS > 24Injury Severity Score

Mo

rta

lity

(%

)

RLHMSHCH

*

*

Comparative Mortality

Damage Control Resuscitation

1. Early haemorrhage control (DCS)2. Permissive hypotension3. Limit fluid infusions (dilution)4. Target coagulopathy