Improving mortality in trauma laparotomy through the evolution of damage control resuscitation

Joseph, Bellal; Azim, Asad; Zangbar, Bardiya; Bauman, Zachary M.; OʼKeeffe, Terence; Ibraheem, Kareem; Kulvatunyou, Narong; Tang, Andrew; Latifi, Rifat; Rhee, Peter

doi:10.1097/ta.0000000000001273

Cited by 51 publications

(45 citation statements)

References 32 publications

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“…A mortality rate of 16.7% was found in the current cohort series, which is comparable to recent literature with mortality rates ranging from 7 to 17% [24][25][26]. In almost half of our patients, cause of death was considered neurological.…”

Section: Discussionsupporting

confidence: 85%

Outcome of trauma-related emergency laparotomies, in an era of far-reaching specialization

et al. 2019

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Background: Far reaching sub-specialization tends to become obligatory for surgeons in most Western countries. It is suggested that exposure of surgeons to emergency laparotomy after trauma is ever declining. Therefore, it can be questioned whether a generalist (i.e., general surgery) with additional differentiation such as the trauma surgeon, will still be needed and can remain sufficiently qualified. This study aimed to evaluate volume trends and outcomes of emergency laparotomies in trauma. Methods: A retrospective cohort study was performed in the University Medical Center Utrecht between January 2008 and January 2018, in which all patients who underwent an emergency laparotomy for trauma were included. Collected data were demographics, trauma-related characteristics, and number of (planned and unplanned) laparotomies with their indications. Primary outcome was in-hospital mortality; secondary outcomes were complications, length of ICU, and overall hospital stay. Results: A total of 268 index emergency laparotomies were evaluated. Total number of patients who presented with an abdominal AIS > 2 remained constant over the past 10 years, as did the percentage of patients that required an emergency laparotomy. Most were polytrauma patients with a mean ISS = 27.5 (SD ± 14.9). The most frequent indication for laparotomy was hemodynamic instability or ongoing blood loss (44%).Unplanned relaparotomies occurred in 21% of the patients, mostly due to relapse of bleeding. Other complications were anastomotic leakage (8.6%), intestinal leakage after bowel contusion (4%). In addition, an incisional hernia was found in 6.3%. Mortality rate was 16.7%, mostly due to neurologic origin (42%). Average length of stay was 16 days with an ICU stay of 5 days. Conclusion: This study shows a persistent number of patients requiring emergency laparotomy after (blunt) abdominal trauma over 10 years in a European trauma center. When performed by a dedicated trauma team, this results in acceptable mortality and complication rates in this severely injured population.

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Section: Discussionsupporting

confidence: 85%

Outcome of trauma-related emergency laparotomies, in an era of far-reaching specialization

et al. 2019

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“…9 The difference in mortality between this study and those data appears to be due to fundamentally different patient populations. That study excluded patients who died within 30 minutes of surgical start and the data reported here included only patients whose time from ED to surgical start was ≤90 minutes.…”

Section: Discussioncontrasting

confidence: 52%

Mortality after emergent trauma laparotomy

Harvin

Maxim

Inaba

et al. 2017

Journal of Trauma and Acute Care Surgery

123

103

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Background Two decades ago, hypotensive trauma patients requiring emergent laparotomy had a 40% mortality. In the interim, multiple interventions to decrease hemorrhage-related mortality have been implemented but few have any documented evidence of change in outcomes for patients requiring emergent laparotomy. The purpose of this study was to determine current mortality rates for patients undergoing emergent trauma laparotomy. Methods A retrospective cohort of all adult, emergent trauma laparotomies performed in 2012–2013 at 12 Level I trauma centers was reviewed. Emergent trauma laparotomy was defined as emergency department (ED) admission to surgical start time in ≤90 minutes. Hypotension was defined as arrival ED systolic blood pressure (SBP) ≤90 mmHg. Cause and time to death was also determined. Continuous data are presented as median [IQR]. Results 1,706 patients underwent emergent trauma laparotomy. The cohort was predominately young (31 years [24, 45]), male (84%), sustained blunt trauma (67%), and with moderate injuries (ISS 19 [10, 33]). The time in ED was 24 minutes [14, 39] and time from ED admission to surgical start was 42 minutes [30, 61]. The most common procedures were enterectomy (23%), hepatorrhaphy (20%), enterorrhaphy (16%), and splenectomy (16%). Damage control laparotomy was utilized in 38% of all patients and 62% of hypotensive patients. The Injury Severity Score for the entire cohort was 19 (IQR 10, 33) and 29 (IQR 18, 41) for the hypotensive group. Mortality for the entire cohort was 21% with 60% of deaths due to hemorrhage. Mortality in the hypotensive group was 46%, with 65% of deaths due to hemorrhage. Conclusion Overall mortality rate of a trauma laparotomy is substantial (21%) with hemorrhage accounting for 60% of the deaths. The mortality rate for hypotensive patients (46%) appears unchanged over the last two decades and is even more concerning, with almost half of patients presenting with a SBP ≤ 90 mmHg dying. Level of Evidence Level III (retrospective epidemiologcal study with up to two negative criteria)

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“…Use of this approach has been demonstrated to improve mortality, facilitate earlier abdominal closure, decrease healthcare costs, and decrease length of stay. 9,11,[15][16][17] These include hypotensive resuscitation techniques, early airway control, early use of blood and blood products, and other hemostatic agents.…”

Section: Tenets Of Dcrmentioning

confidence: 99%

Damage control resuscitation

et al. 2020

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The United States Navy originally utilized the concept of damage control to describe the process of prioritizing the critical repairs needed to return a ship safely to shore during a maritime emergency. To pursue a completed repair would detract from the goal of saving the ship. This concept of damage control management in crisis is well suited to the care of the critically ill trauma patient, and has evolved into the standard of care. Damage control resuscitation is not one technique, but, rather, a group of strategies which address the lethal triad of coagulopathy, acidosis, and hypothermia. In this article, we describe this approach to trauma resuscitation and the supporting evidence base.

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Improving mortality in trauma laparotomy through the evolution of damage control resuscitation

Abstract: Prognostic study, level III.

Cited by 51 publications

References 32 publications

Outcome of trauma-related emergency laparotomies, in an era of far-reaching specialization

Outcome of trauma-related emergency laparotomies, in an era of far-reaching specialization

Mortality after emergent trauma laparotomy

Damage control resuscitation

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