Moore Retreat: Damage Control Laparotomy

Identify who needs a damage control lap:
- Temperature, acidosis, coagulopathy
- temperature should be largely controlled: bear huggers in ER, warm fluids; in Denver not an issue as pts rarely get to OR with temp<36.  With longer transports most of our pts hypothermic, pre-hospital bear huggers?
- Acidosis can be controlled with bicarb, Denver is quite liberally with use of bicarbonate during trauma resuscitation
- Most significant factor is coagulopathy
- Need for resuscitation should not be indication of damage control. Can resuscitate as well or better in OR vs. ICU

Newer evidence to demonstrate that ARDS is better with isofluorane vs. propofol sedation
- pt in OR on volatile anesthetics may in fact be safer than in ICU from respiratory standpoint

30 Minute Time out:
- pack site of bleeding for 30 mins
- close abdomen with towel clips and then go back and check for further bleeding
- warm patient, resuscitate
- when you go back look for arterial bleeding
- better than sending back to ICU with arterial bleeding

Temporary Abdominal Closures:
- all pts in Denver get abdominal compartment syndrome
- Vac closure is preferred method of closure
- They even apply this to select abdominal sepsis patients
- Relaparotomy in 12-24 hours: especially if shunts used or contamination
- patients very quickly go from being hypocoaguable to hypercoaguable

Abdominal Closure techniques:
- staged tension closure
1) Plastic drape
2) Nylon retention sutures
3) Repeat laparotomy every 48hours and place interrupted sutures each time gradually closing the abdomen
(AJS 2007)

Diuresis:
- Gives a 10mg Lasix trial
- if the patient responds and diureses he then starts a lasix gtt to aggressively diurese for closure
- if pt doesn't respond then he waits

Pearls:
- Chest can also be closed temporarily with plastic drapes