Damage Control in Abdominal Trauma

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

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

Time to OR Pediatric Solid Organ Injury 1818 pts (7 PTC; 1997-2002) 89 pts (5%) to OR Median time to OR: 3 hrs 59% within 4 hrs 76% within 12 hrs 1813 pts (NTDB; 1991-2003) 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

% Impact of Guidelines?

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

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

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

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

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!

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

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

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

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

Solid Organ Tract Hemorrhage Balloon Tamponade

Total Hepatic Vascular Occlusion

Lap Pad Packing

Abdominal Packing in Children JPS - 1998 22 patients (age: 6d to 20y) Trauma; tumors; NEC Peri-hepatic: 64% Transfusion: 190 ml/kr All were in shock ( triad )

Abdominal Packing in Children JPS - 1998 Use at primary OP: 68% Control of bleeding: 95% Abscess formation: 32% Survival: 82%

Your Patient is Bleeding Do Something!

Contrast blush on CT

Angio-Embolization

Splenic Embolization in Injured Children What are the selection criteria?

Proximal vs Distal Splenic Artery Embolization J Trauma 2011 Los Angeles Systematic/meta-analysis in adults (1995-2008) Proximal embolization: - decreases flow - promotes clot formation - reduces infarction - without a higher re-bleed rate.

Pelvic Fracture Hemorrhage

Extraperitoneal Pelvic Packing

Pelvic Compression/Packing

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

Coagulopathy of Trauma

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

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

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

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

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?

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

Recombinant Factor VIIa Vick and Islam; JPS 2008 8 children with Grade III-IV injury Used in NOM; all but 1 transfused 75-90 micrograms/kg No adverse thromboembolic events

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

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

Temporary Abdominal Wall Closure

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

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

Abdominal Compartment Syndrome in Children Neville, et al; JPS - 2000 23 patients (NEC, trauma) FiO 2 : 0.87 to 0.67; p<0.01 PIP: 33 to 27; p<0.01 Survival: 65%

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!

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