Cambridge Damage Control Symposium
by Alan Batt. Last modified: 25/11/14
The Cambridge Damage Control Symposium was held in the Mohammed Bin Rashid Academic Medical Center in Dubai Healthcare City on the 24th November 2014. I was kindly sent by National Ambulance LLC as a member of their Clinical Education Team, and they have allowed me to produce this report for both staff of National Ambulance and for the FOAM community.
Damage control resuscitation is a term used to encompass the range of strategies focused on balancing haemostatic resuscitation, permissive hypotension, lung protection, wound protection and neuro-protection whilst maintaining tempo and critical organ and system support.
In this symposium, experienced members of pre-hospital and emergency department trauma teams looked at current damage control resuscitation strategies and discussed the practical considerations in implementing them.
The day started with Dr. Rod McKenzie, Consultant in Emergency Medicine and director of the Major Trauma Centre at Addenbrooke Hospital, and prehospital physician with London Air Ambulance.
Components of Damage Control Resuscitation
A – Airway Management
The day followed the ATLS standard A-B-C-D-E approach to Damage Control Resuscitation. First up was Airway. Some of the key points from this talk were:
Decisions for prehospital anaesthesia are not based on GCS criteria! Candidates for perhospital anaesthesia and airway control are:
- Failure to maintain the airway
- Failure to protect
- Failure to oxygenate
- Failure to ventilate
- Expected clinical course
Always weigh up the risk of anaesthesia versus the risk of none.
Is it an airway problem v breathing problem?
- Near death (agonal respirations/cardiac arrest/anticipated laryngoscopy) = crash intubation
- Not near death = Assess for difficult DL or BVM. If difficult then reconsider risk/benefit
There is no such thing as a failed intubation…it is failed laryngoscopy.
BVM is important for rescue of airway!
- Plan A – RSI > DL > Bougie/ET
- Plan B – rescue ventilation
- Plan C – rescue oxygenation
- Plan D – Surgical
Ref Difficult Airway Society (http://www.das.uk.com/files/rsi-Jul04-A4.pdf)
Crash intubation = facemask, BVM to provide oxygenation. Equipment dump if possible.
Failed plan A or B = go to plans C/D
Sux useful if near-death and patient has increased muscle tone/trismus.
Consider primary surgical airway in difficult airway prediction (max-fax injuries, access difficult)
- Paralysis with induction
- Placement with proof
- Postintubation management
Is the patient LEMON positive?
Don’t forget adequate preoxygenation! Desaturation occurs faster in different patient populations.
Time to Desaturation for Various Patient Circumstances. Source: From Benumof J, Dagg R, Benumof R. Critical hemoglobin desaturation will occur before return to an unparalyzed state following 1 mg/kg intravenous succinylcholine. Anesthesiology 1997;87:979.
- Optimise the airway!
- Complete checklist – “to err is human”
- Then proceed.
- Can use ketamine for induction (2mg/kg normal; 1mg/kg in frail,shocked,elderly)
- NB – sux is based on actual body weight
- Don’t keep it to yourself, verbalise what you can see under DL
- Cannot understate capnography!!
- Movement is high risk – increasingly indefensible to not have capnography, even on SGAs
- If 1st attempt failed, don’t just do the same again!
B – Ventilatory Support & Lung Protection
ATLS Deadly Dozen!
Prevent Lung Injury
- Reduced Expansion
- Pain & narcotics
- Increased work of breathing
- Pulmonary haemorrhage
- Excess fluid administration
- Structural damage
What is lung protection?
- Optimise O2 delivery
- Minimise further injury
Ventilation – alveolar mechanics videos
Low Tidal Volume ventilation: http://www.youtube.com/watch?v=eK19izkSQZo
High Tidal Volume Ventilation: http://www.youtube.com/watch?v=M9uI9xKWW-E
Injured lungs = baby lungs. Any ventilation is harmful
Decrease volume, increase rate, increase FiO2, +/-PEEP
e.g. 6ml/kg; 12bpm; 0.6-1.0 FiO2; PEEP 5
- Have a low threshold for open thoracostomy.
- Intubated, PPV, thoracic injury = open thoracostomy.
- Classic ATLS signs of tension pneumothorax are uncommon!
- Differentiate spontaneous respiration v ventilated pneumothorax
- We miss flail segments…around the back!
- Humidification and other ARDS approaches can reduce lung injury
C – Circulatory Support
We’re relearning the lessons of war.
Haemostatic resuscitation – preserve blood, not replace it!
- Stop compressible bleeding
- Reduce non-compressible bleeding
- Prevent coagulopathy
- Administer TXA
- Consider risk/benefit of transfusion
- If transfusing then balanced RBC:FFP:Plat on a 1:1:1 ratio
Don’t forget the bleeding basics!
- Direct pressure!
- Pressure dressing
- Haemostatic agent
Basic equipment, aggressive search for bleeding & show no mercy to blood loss!
Celox – pack the wound
- Most bleeding patients are already coagulopathic or are at high risk of coagulopathy
- Hypothermia, blood loss etc – stop!
- Assume coagulopathy – manage before labs
- Give no fluids that do not clot or carry oxygen!
In a small subset of patients permissive hypotension may be useful. MTP activated (just in case), keep shocked until OR. Penetrating trauma mostly. If conscious on arrival – always watching perfusion (mentation)
Goals are not always achievable however. There is no literature on permissive hypotension in blunt trauma.
Tube thoracostomy if bleeding – insert drain; we should be auto-transfusing this blood back in!
CRASH2 Trial: 274 hospitals, 40 countries, 20000+ pts.
- 32% reduction in RIP
Blood – pre-alert or use if you have! MTP needs prealert!
D – Neuroprotection
Single hypotensive or hypoxic episode = 2 x RIP
Goal is the prevention of 2nd degree brain injury
4 Hs of secondary injury
The following two tabs change content below.Paramedic, educator, researcherAlan is a critical care paramedic, paramedic educator and prehospital researcher, currently working around the world as an educator and researcher. He has previously worked and studied across Europe, North America and the Middle East. He holds a Graduate Certificate in Intensive Care Paramedic Studies, and an MSc in Critical Care. His main interests are in care of the elderly, end-of-life care, patient safety, professionalism (including role and identity), and paramedic education.
- SpO2 ~ 92%.
- MAP > 80 mmHg (to maintain CPP/CBF)
- Low N Co2 4-4.5kPa/35-45mmHg. Watch the ETCO2. Mortality >if ETCO2 outside N. If unequal pupils, hyperventilate to ETCO2 of 3kPa
- Maintain temp 35-37C
- Ideally 4 hrs from injury to surgery – actually ASAP!
Latest posts by Alan Batt (see all)
- Free access: Resuscitation Today Vol 3 Issue 2 - 27/06/16
- Free CPD at the Emergency Services Show - 23/05/16
- Care at the Scene – Research for Ambulance Services - 17/05/16
- Canadian Paramedicine Feb/Mar 2016 – Open Access Issue - 11/04/16
- Eat, sleep and be healthy – a paramedic’s guide to healthier shift work - 10/04/16
Cambridge Damage Control Symposium
Get weekly email updates!
Cast Your Vote
- Blogs (40)
- Case Studies (8)
- Featured Article (23)
- How-To (47)
- FOAM (8)
- News (117)
- Conference Tweets (31)
- Pharmacology (1)
- Adrenaline (1)
- Research (180)
- Advanced Practice (2)
- Airway Management (6)
- Anaphylaxis (2)
- Cardiac (15)
- Community Paramedic (2)
- Critical Care Paramedic (4)
- Diagnostics (3)
- Dispatch (1)
- ECG (4)
- Education (10)
- EMS Operations (2)
- End-of-Life Care (3)
- Geriatrics (9)
- Guidelines (22)
- HEMS (4)
- Mass Casualty (2)
- Medical Conditions (5)
- Mental Health (7)
- Military & Tactical (2)
- Neonatal (1)
- Neuro (11)
- Obstetrics (1)
- Paediatrics (4)
- Pain Management (4)
- Poster Presentations (5)
- Professionalism (5)
- Remote, Industrial & Austere (6)
- Respiratory (5)
- Resuscitation (27)
- Rural (3)
- Safety (3)
- Sepsis (7)
- Shock (2)
- Simulation (7)
- Sports Medicine (1)
- Trauma (20)
- Reviews (6)
There are no upcoming events at this time.
- Free access: Resuscitation Today Vol 3 Issue 2 (27/06/16)
- Free CPD at the Emergency Services Show (23/05/16)
- Canadian Paramedicine Feb/Mar 2016 – Open Access Issue (11/04/16)
- Free access: Resuscitation Today Volume 3 Issue 1 (01/04/16)
- Introducing the Irish Journal of Paramedicine (22/11/15)
Latest How-To Articles
- Paramedic students…write something! (28/04/16)
- Understanding diagnostic tests 2: likelihood ratios, pre- and post-test probabilities and their use in clinical practice (30/01/15)
- Understanding diagnostic tests 1: sensitivity, specificity and predictive values (11/12/14)
- GRADE guidelines – best practices using the GRADE framework (22/11/14)
- How to get started with EMS research – JEMS (16/05/14)
academic ACS AED airway management ambulance AMI Australia Canada cardiac cardiac arrest case study CCP clinical management computer conference consensus CPG CPR CPR UL critical care CVA database education elderly EMS epinephrine evidence based FOAM FPHC geriatric guide guidelines haemorrhage HEMS immobilisation Ireland journal medication mental health neurology news OHCA online pain management paramedic prehospital PTSD reference research resuscitation review ROSC safety Scotland sepsis septic shock simulation social media software spinal STEMI stroke study TBI training Translational Health Sciences trauma Twitter UK USA