Damage control laparotomy

Three dark angels: acidosis, coagulopathy, hypothermia

Indications
SBP<90
Temp<34
APTT>60
pH<7.2
Pattern recognition
Lactate >5
Inability to achieve haemostasis owing to coagulopathy
time consuming procedure (>90 min)
inaccessible major venous injury
life threatening injury in second location
planned reassessment of abdominal contents
inability to close abdomen

Aims:
Control haemorrhage: pack all quadrants
must control surgical bleeding definitively
pack medical bleeding
simple vascular ligation, balloon tamponade or shunting
perform rapid exploration
control contamination
staplers or tapes
don't waste time creating stomas
drain tubes for biliary or urological injuries
pack abdomen
perform temporary abdominal closure
avoids compartment syndrome

procedure
aim <1hr
warm theatre to 27
have packs available
prep from neck to knees
full length incision to fascia then through fascia
avoid sucker use initially
scoop out blood and pack abdomen

Definitive haemostasis
Splenectomy (can be done <2mins)
clamp mesenteric bleeding
nephrectomy
packing of liver and adjuncts
if unable to gain control: cross clamp aorta
control bleeding from visible vessels
consider temporary vascular shunts
Balloon occlusions of vessels
Can tie off IVC below renal vessels (consider lower limb fasciotomies)
drainage for pancreatic injuries
washout
Close: towel clips
Bogota bag
VAC
Remember angiography esp for pelvis and liver

When to reoperate
lactate <4
base excess >4
normalised coagulation profile

Relook
perform definitive operations before pack removal
restore intestinal continuity
'tertiary' survey

complications
most common is compartment syndrome (15%)
(renal failure occurs when pressure >25mmHg)
infection
-associated with packing itself, not just contamination. Also with hepatic artery ligation