Damage Control in Abdominal Trauma

Transcription

1 Damage Control in Abdominal Trauma Steven Stylianos, MD Surgeon-in-Chief, Morgan Stanley Children s Hospital Rudolph Schullinger Professor of Surgery, Columbia University College of Physicians & Surgeons

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3 Background NOM successful in children with severe solid organ injuries (>88% NOM in Grade IV) JPS 2000; 2002; 2008 Most failures within 6-12 hours J Trauma 2005; 2006 The challenge of teaching psychomotor skills for hemostasis of solid organ injury J Trauma 2009

4 Time to OR Pediatric Solid Organ Injury 1818 pts (7 PTC; ) 89 pts (5%) to OR Median time to OR: 3 hrs 59% within 4 hrs 76% within 12 hrs 1813 pts (NTDB; ) 120 pts (7%) to OR Median time to OR: 2.4 hrs 79% within 6 hrs 90% within 24 hrs» J Trauma 2005» J Trauma 2006

5 % Impact of Guidelines?

6 Damage Control Definition Rapid hemostasis (ligation, stenting, packing, fixation) Control contamination Temporary abdominal wall closure Resuscitation in ICU

7 Damage Control Single GSW to Lt 6 th ICS in Dallas, 1963 Diaphragm Spleen Stomach Pancreas Aorta/SMA IVC Rt Kidney Liver

8 Damage Control? 107 minutes in OR Scoop and run EBL: 6000 ml 16 units PRBC 4 liters RL Temp? Coags? ph? trauma was too great for resuscitation

9 Damage Control Topics When / How / Where? Hemorrhage Physiology Abdominal Wall

10 Damage Control Topics When / How / Where? Hemorrhage Physiology Abdominal Wall

11 Damage Control When? Increased emphasis on physiologic/metabolic state Triad of hypothermia, acidosis, and coagulopathy Success of damage control depends on decision prior to irreversible shock Damage control represents advanced surgical care!

12 Damage Control Strategy How? - 3 Phases Phase 1 Phase 2 Abbreviated laparotomy Control of hemorrhage and contamination Packing and temporary abdominal wall closure Aggressive ICU resuscitation Core re-warming Optimize volume/o 2 delivery Correct coagulopathy

13 Damage Control Strategy Phase 3 Planned re-operation for packing change and washout Definitive repair of injuries Abdominal wall closure

14 Damage Control Where? Any hospital; Battlefield Facilitates transfer Trauma ICU Interventional radiology ERCP

15 Damage Control Topics When / How / Where? Hemorrhage Physiology Abdominal Wall

16 Damage Control Hemorrhage Temporary stenting Packing/tamponade Angio-embolization Recombinant FVIIa Tranexamic acid

17 Solid Organ Tract Hemorrhage Balloon Tamponade

18 Total Hepatic Vascular Occlusion

19 Lap Pad Packing

20 Lap Pad Packing

21 Abdominal Packing in Children JPS patients (age: 6d to 20y) Trauma; tumors; NEC Peri-hepatic: 64% Transfusion: 190 ml/kr All were in shock ( triad )

22 Abdominal Packing in Children JPS Use at primary OP: 68% Control of bleeding: 95% Abscess formation: 32% Survival: 82%

23 Your Patient is Bleeding Do Something!

24 Contrast blush on CT

25 Contrast blush on CT

26 Angio-Embolization

27 Splenic Embolization in Injured Children What are the selection criteria?

28 Proximal vs Distal Splenic Artery Embolization J Trauma 2011 Los Angeles Systematic/meta-analysis in adults ( ) Proximal embolization: - decreases flow - promotes clot formation - reduces infarction - without a higher re-bleed rate.

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30 Pelvic Fracture Hemorrhage

31 Extraperitoneal Pelvic Packing

32 Pelvic Compression/Packing

33 Damage Control Topics When / How / Where? Hemorrhage Physiology Abdominal Wall

34 Damage Control Physiology Triad Hypothermia Acidosis Coagulopathy (1:1:1)

35 Coagulopathy of Trauma

36 Damage Control Triad Effects Pro-coagulant enzymes Fibrinolysis Platelet activation Platelet adhesion The Coagulopathy of Trauma J Trauma Oct 08

37 Coagulopathy in Pediatric Trauma Traumatic coagulopathy is a complex process that leads to global dysfunction of the endogenous coagulation system resulting in worse outcomes and increased mortality. Although the cause is multifactorial, it is common in severely injured patients and is driven by significant tissue injury and hypoperfusion. Viscoelastic coagulation tests (TEG /ROTEM ) have been established as a rapid and reliable method to assess traumatic coagulopathy and produce a dynamic picture of the entire coagulation process. - Curr Opin Pediatr 2014

38 Massive Transfusion Protocols Prospective, randomized trials and retrospective analyses support the use of a restrictive packed RBC transfusion policy in most clinical conditions in children. Current transfusion practices for both platelets and coagulant products (e.g., fresh-frozen plasma and recombinant-activated factor VII) are poorly aligned with recommended guidelines. Greater efforts to implement current evidence-based transfusion practices are needed. - Crit Care Med 2014

39 Tranexamic Acid Anti-fibrinolytic that inhibits the activation of plasminogen to plasmin, thus decreasing the degradation of fibrin. Tranexamic acid has 8X the activity of ε-aminocaproic acid. Benefit in military setting (Arch Surg 2012) No benefit in urban trauma center (J Trauma 2014) Use in pediatric ENT, CV and Ortho surgery No studies in injured children

40 Recombinant Factor VIIa Dilution/Stored blood products Clot promotion; Activate FXa Effective during hypothermia Thromboelastography (Ped Crit Care Med 2009) Last ditch administration is futile Thrombo-embolic risk?

41 Safety and Efficacy of rfviia in Refractory Traumatic Hemorrhage - J Trauma 2010 CONTROL randomized Phase 3 Trial 573 pts; 4-8 PRBC in 12 hours End-point futility due to low mortality rfviia reduced blood product use but no affect on mortality

42 Recombinant Factor VIIa Vick and Islam; JPS children with Grade III-IV injury Used in NOM; all but 1 transfused micrograms/kg No adverse thromboembolic events

43 Damage Control Topics When / How / Where? Physiology Hemorrhage Abdominal Wall

44 Damage Control Abdominal Wall Temporary expansion Facilitate re-exploration Abdominal compartment syndrome

45 Temporary Abdominal Wall Closure

46 Temporary Abdominal Wall Closure

47 Temporary Abdominal Wall Closure

48 Temporary Abdominal Wall Closure

49 Temporary Abdominal Wall Closure

50 Temporary Abdominal Wall Closure VAC results in lower volume reserve capacity and increased risk of recurrent IAH J Trauma April 2009

51 Abdominal Compartment Syndrome Sequelae Cardiovascular Pulmonary Renal Occult GI - J Trauma 2009

52 Abdominal Compartment Syndrome in Children Neville, et al; JPS patients (NEC, trauma) FiO 2 : 0.87 to 0.67; p<0.01 PIP: 33 to 27; p<0.01 Survival: 65%

53 Damage Control Summary Emphasis on physiologic/metabolic state Must be employed prior to irreversible shock Systematic, staged, multi-disciplinary approach Represents advanced surgical/trauma care!

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57 Pediatric Trauma in US Leading cause of death in children > 1 year 22,000 deaths/year (age < 14 y) 600,000 hospitalizations/year 1 in 4 children require emergency visit Cost > $5 billion/year