Damage-Control Laparotomy (Polytrauma)
Patient phenotype
Penetrating abdominal trauma, blunt with hemodynamic instability, or 'destruction' injuries. Often: hypotensive, acidotic, coagulopathic, hypothermic on arrival. Time-critical.
Procedure
Goal: STOP BLEEDING + STOP CONTAMINATION, then close temporary (vac dressing) and go to ICU for resuscitation, return to OR in 24-48h for definitive repair. Operating goals are limited: hemorrhage control + bowel control. < 90 min ideal.
Anesthetic plan
Damage control resuscitation: 1:1:1 transfusion, permissive hypotension (SBP 80-90 until bleeding controlled), hypothermia prevention, calcium replacement, TXA early. RSI on table. ICU intubated, do NOT extubate.
Setup
- ·MTP activated before patient arrives if possible
- ·2-3 large-bore PIVs OR central access (quick MAC catheter via subclavian)
- ·Two A-lines if possible
- ·Belmont rapid infuser primed with PRBC
- ·TEG/ROTEM at bedside
- ·Calcium chloride drawn
- ·Forced air warmer + fluid warmer + ambient temp 80°F
- ·Type O- blood for empiric transfusion before type & cross
Biggest concerns by phase
Permissive hypotension until hemorrhage controlled
SBP 80-90 mmHg target until surgical hemorrhage control. Higher pressures dislodge clots, increase ongoing bleeding. EXCEPTION: TBI patients need MAP > 65 (CPP). Use vasopressors sparingly — they don't replace volume.
RSI in shock — drug + dose modification
Etomidate 0.1 mg/kg OR ketamine 0.5 mg/kg (low dose due to shock state). Sux 1.5 mg/kg or roc 1.2 mg/kg. Have pressors drawn + start vasopressor immediately if MAP drops further.
Lethal triad: hypothermia + acidosis + coagulopathy
Each potentiates the others. Aggressive prevention: warm fluids (Belmont), warm OR, warmed irrigation, body covered when possible. Bicarb if pH < 7.20. Calcium 1g per 4 units PRBC. Reverse anticoagulants if relevant (PCC for warfarin, idarucizumab for dabigatran, andexanet for FXa inhibitors).
TXA within 3 hours — 1g IV bolus + 1g over 8h
CRASH-2 + MATTERs trial: TXA reduces mortality if given < 3h post-injury. > 3h: may be harmful. Standard dose: 1 g IV over 10 min, then 1 g infusion over 8h.
Goal-directed transfusion with TEG/ROTEM
1:1:1 (PRBC:FFP:platelets) initial. Then refine: low MA → platelets, low alpha → cryo (fibrinogen < 200), prolonged R → FFP/PCC. Avoid LR (citrate-Ca interaction in massive transfusion), avoid 5% albumin (no clotting factors).
ICU intubated — DO NOT extubate, plan return to OR
Post-damage-control, patient still acidotic, coagulopathic, possibly with abdominal compartment syndrome under temporary closure. ICU course: continued resuscitation, warming, correction. Return to OR 24-48h for definitive repair when physiology corrected.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
Multiple GSW to abdomen, BP 70/30, HR 140, GCS 13. You've given 6 PRBC, 6 FFP, 1 platelet pheresis, 2g TXA. Bleeding controlled, abdomen open with vac. INR 1.6, fibrinogen 130, ionized Ca 0.85, temp 34.8, pH 7.18. Surgeon wants to close. What do you do?
What an examiner probes for
- ▹Recognize damage-control physiology — patient too sick to close
- ▹Plan: leave abdomen open, transport intubated to ICU
- ▹Continue resuscitation: cryo for fibrinogen, calcium, bicarb
- ▹Warming, fluid + product replacement
- ▹Communicate plan: return in 24-48h for definitive repair
Sources
- ATLS 10e
- ASA Trauma Anesthesiology
- Joint Trauma System Clinical Practice Guidelines
Anatomy reference
Sourced reference images. 4 matches for "abdomen bowel peritoneum".
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