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Can we provide level III damage control surgical procedures at a level II facility?

Introduction

Most experienced combat surgeons who have been involved in multiple damage control laparotomies and extremity amputations will tell you that wounded arrive to a surgical facility in one of three prognostic states. The first group of patients are the least injured and will do well without immediate care or even survive a prolonged duration before a surgical procedure and require minimal blood product support (approximately 100% survival). The second group is the massively injured patient with multiple large issue defects and destruction that will not survive under any circumstances, despite any imaginable intervention available at this time in history (0% survival). The third group are those that arrive in Class IV shock, cold, coagulopathic and acidotic with a wounding pattern that is amendable to immediate surgical hemostasis (ligation of vessels and packing of wounds). These casualties will the unless maximal efforts are made at blood Product replacement and patient warming. These patients often require 10-50 units of packed Red Blood Cells (PRBCs), Factor VIIa (rFVIIa), and fresh whole blood to survive in the first 24 hours. This third group of patients currently are candidates for damage control surgical procedures at our Level IIb facilities. (1) Damage control surgery in civilian trauma centers is based on the U.S. Navy term used to describe "the capacity of a ship to absorb damage and maintain mission integrity." (2)

Translating this idea to surgery of severely injured trauma patients evolved into a three phase process; (1) an initial "damage control" abbreviated laparotomy to stop all hemorrhage and gastrointestinal tract soilage, (2) Intensive care unit (ICU) resuscitation and rewarming, and (3) return to the operating room (OR) for definitive treatment of all injuries when maximally stabilized. (3) While the civilian paradigm utilizes a damage control "trilogy," the deployed military damage control paradigm has the additional challenges of a tactical evacuation to a surgical facility and then a helicopter evacuation in the middle of the ICI resuscitation and possibly a global evacuation to Germany or the continental United States before or after the definitive operation. The goals for resuscitation in civilian trauma center ICU before transfer to OR are stated as a temperature >36[degrees]C, Base deficit >-5, normal lactate, Prothrombin time (PT) <15 seconds. Partial thromboplastin time (PTT) <5 seconds, platelet, >50,000, Fi[O.sub.2] of <0.50. (4) Optimally, these same goals for resuscitation should apply to Level IIb facilities prior to helicopter evacuation to the next echelon of care. One could make the argument that these goals for resuscitation are of even more importance to deployed military damage control as the physiologically challenging, helicopter evacuation provides minimal opportunities for in-flight monitoring and continued resuscitation. Due to logistical limitations in an austere environment, the OR/ICU resuscitation phase of damage control currently represents the greatest challenge to currently deployed FSTs.

This article will evaluate the differences in the surgical capabilities of the Level IIb facility (FST) compared to a Level III facility Combat Surgical Hospital (CSH) and elucidate the small yet significant changes that can be made to give the Level IIb facilities the capability to rewarm and adequately resuscitate damage control patients. These changes need to he made and still retain the unique mobility of the FST. While the CSH has many capabilities (for example, Dental, CT scanners, etc) not directly involved with damage control, we will concentrate only on the "surgical slice" from emergency room (ER) to postoperative monitoring and will evaluate the feasibility of prodding Level III damage control at the Level fib facilities. Increasing the survival rate of patients undergoing damage control procedures may represent the only way to significantly decrease the died of wounds rate of combat wounded arriving alive to facilities with surgical capability in current and in any near future conflicts.

The following tables (see Table 1, page 62) will compare current capabilities of Level IIb and Level III facilities.

Discussion

Emergency Room. The combat wounded who arrive straight from the field or from a Level I facility are initially evaluated in the civilian equivalent area of a trauma bay. The capabilities for treating trauma patients at these two facilities are very similar (Table 1). Following the lead of civilian trauma centers using "hypotensive resuscitation" blood product transfusions in the ER are limited. (5) The only blood products available for initial resuscitation at both Level IIb and Level III are uncrossed matched PRBCs. The minority of Level IIb facilities have a fluid warmer/rapid infusion system (for example, Level One[R] or Belmont[R]). While the Level III facilities have the capability to perform a chest X-ray, if a patient arrives at a Level II facility with the question of a pneumothorax this entity can be made irrelevant by the placement of bilateral chest tubes. Unstable blunt trauma patients can be evaluated by abdominal ultrasound at both facilities (for example. Sonosite[R]). Overall, the care and resuscitation of the damage control casualty in the trauma bay at current Level IIb and Level III should be considered equivalent,

Operating Room. The majority of damage control procedures are performed by two general surgeons at both facilities. The major differences in the operating theatres is the inability to control temperature at Level IIb, limited critical supplies, and blood products. While overhead lighting at the Level IIb facilities is limited, the availability of excellent headlamps can make the difference in operative lighting negligible during the majority of damage control procedures. A standard operating table with the addition of a Buchwalter retractor at Level III can be negated with the use of medic and OR tech hand held retraction. The quantity of laparotomy pads and GIA staplers often are a concern at Level IIb facilities and are more available at Level III facilities (Table 2).

Overall, general surgeons skilled in trauma care can technically perform damage control surgical procedures in current Level IIb facilities as can be performed in Level III facilities.

Postostoperative Care. The postoperative monitoring of patients in the ICU setting is based mainly on vital signs, urine output, hematocrit and ISTAT[R] base deficit (lactate cartridges are available from the ISTAT[R] manufacturer but were not used routinely in Operation Iraqi Freedom [OIF]-1 or OIF-2). Many Level IIb facilities have the laboratory values from an ISTAT and this is also used frequently at the Level III facilities. The PT and the PTT are determined at the Level III laboratory and are not available for Level IIb surgeons. While arterial line monitoring and central venous pressure monitoring are available at both the majority of Level IIb facilities and Level III facilities, Swann--Ganz catheters are not and would be of little help in but possibly a few older patients with clinical confusion regarding resuscitation. The limited number of nurses available to a Level II facility would of course limit the number of postoperative patients that could be monitored.

Overall, the equipment capabilities of Level IIb and Level III are very similar for monitoring an individual postoperative damage control patient (Table 3).

Blood/Blood Products. Level IIb facilities have at least 20 units of PRBCs but no other blood products available (Table 4). In the authors experience, a single damage control patient has required up to 50 units of blood and blood products within the first 24 hours during OIF-2 and survived. Patients in civilian trauma centers, undergoing the initial damage control operations have massive blood and blood product transfusion requirements with one recent study documenting, an average of 11.2 units of PRBCs, 3.5 units of Fresh Frozen Plasma (FFP) and 4.9 units of platelets. (6) These civilian transfusion requirements documented to increase to 20.4 units of PRBCs, 5.4 units of FFP, and 7.7 units of platelet, transfused for patients described as the "maximum injury subset." (7) Eastridge et al in a review of all patients undergoing a damage control operation during OIF documented an average transfusion requirement of 8.6 units of PRBCs and 0.64 units of whole blood in the first 24 hours for an estimated intraoperative blood loss of 2,384 ccs. (8) Sebesta, et al documented an average transfusion requirement of 12 units of PRBCs, seven units of FFP and 2.5 units of whole blood in 92 patients undergoing damage control laparotomy at the 31st CSH in OIF during 2004. (9) Obviously, one to two damage control patients, will deplete the entire PRBC supply at a FST and will have no ability to transfuse clotting factors or platelets to these hypothermic and coagulopathic patients.

Many FSTs have the ability to draw whole blood but the donor pool is usually very limited and finite. Furthermore, few FSTs have the capability to blood type potential donors. Level III facilities can provide FFP, whole blood drives, cryoprecipitate, unlimited PRBCs by air transport and large on site storage. The Level IIb facilities only method of replacing blood coagulation factors and platelets is to transfuse whole blood which can be very challenging, especially without cross matching and in the face of multiple patient. Factor VIIa, a medication that helps reverse the coagulopathy of trauma, is available at Level III facilities and at some Level IIb facilities.

Thermoregulation. The methods of patient rewarming at the Level III facilities is the use of warm intravenous fluids and blood via a Belmont[R] or Level One[R] fluid warmer, Baer Hugger[R] heating blanket, and warm ambient room temperature. Level IIb facilities have mixed capabilities (this needs to be universal by MTOE) with some having the fluid warmers and Baer Huggers[R]). The ambient room temperature is not a problem in the summer months in Southwest Asia but, during the winter months room temperature regulation is varied and needs to be universal. The assurance of the universal mandatory acquisition of Baer Huggers[R], fluid warmers, and room temperature Control at the Level IIb facilities will make patient warming essentially equivalent to the capabilities at the level III (Table 5).

Bottom Line

Blood and blood product transfusions coupled with hypothermia are the "Achilles' heel" of providing optimal damage control surgery at the Level IIb facility (Table 6).

Employment of FSTs

Focused improvements in the capabilities of FSTs ability to optimally perform damage control surgery is extremely important because during the maneuver phase of a conflict only they can move with the Brigade Combat Teams. Their austere nature is what makes the FST able to maneuver. This same austerity is what makes it of limited use when compared to the expanded capabilities of the CSH, when they become available. This becomes especially obvious when receiving multiple casualties. Due to their inherent limitations, FSTs should be replaced by the robust CSH and the FSTs should redeploy as soon as the maneuver phase is completed.

Future Solutions

This analysis leads one to the striking conclusion that the only areas of significant difference between the Level IIb capabilities and the Level III capability to perform optimal damage control in the first 24 hours (when looking only it the "surgical slice" and a single patient) is the blood and blood product transfusion capability and patient rewarming methods. The other areas of concern can be improved by immediate acquisition of equipment and supplies.

A potential solution to the blood product deficiency of the Level IIb facilities is to think of the FST as a modular component with a Blood team modular unit. A "Blood Augmentation Unit (BAU)" could be created with greater refrigeration capacity with significant increases in the PRBCs storage and, with the addition of a freezer, could provide FFP and Cryoprecipitate. This unit would provide cross matching and would handle whole blood acquisition locally. The BAU would be a two member team with all refrigeration and freezers attached to a wheeled platform (for example, HUMMV). A system could be devised where helicopter transport would provide further resupply with blood and blood products from a fixed facility (for example, PRBCs, whole blood, FFP, cryo from a CSH). Furthering the modular concept, one or two BAUs could collocate with one or two FSTs to provide a significant increase in both surgical and resuscitation capability (FST BAU) over current isolated FSTs. This concept has been operationally validated by the 274th FST in Operation Enduring Freedom.

References

(1.) Employment of forward surgical teams, U.S. Army FM 8-10-25, Washington, DC. undated.

(2.) Surface ship survivability. Navy War Publications 3-20.31. Washington, DC.: Department or Defense; 1996.

(3.) Shapiro M, Jenkins D, Schwab CW, et al. Damage Control: Collective Review J. Trauma. 2000:49:969-978.

(4.) Moore E. Feliciano D, Mattox K, Trauma, 5th edition. McGraw--Hill pub; 2004.

(5.) Bickell WH, Wall MJ, Pepe, PE, et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. NEJM 1994;331:1005-9.

(6.) Johnson JW, Gracias VH. Schwab CW. et al. Evolution in damage control for exsanguinating penetrating abdominal injury. J Trauma. 2001; 51:261-271

(7.) Rotondo MF, Schwab CW, McGonigal MD, et al. "Damage control": An approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma. 1993;35:375-383.

(8.) Eastridge B, Owsley J, Sebesta J, et al. Damage control surgery in a combat environment: U.S. military experience from operation Iraqi freedom. Submitted J of Trauma 2005.

(9.) Sebesta J. Beckley A. Damage control surgery at the 31st combat support hospital. Abstract submitted to Gary Wratten research conference April 2005.

LTC Lorne H. Blackbourne, MC, USA ([dagger])

COL John B. Holcomb, MC, USA ([double dagger])

([dagger]) Medical Corps, U.S. Army. Lieutenant Colonel Blackbourne is a General Surgeon, U.S. Army Institute of Surgical Research. Fort Sam Houston. TX.

([double dagger]) Medical Corps, US, Army. Colonel Holcomb is a General Surgeon, Consultant to the U.S. Army Surgeon General for Trauma and Commander, U.S. Army Institute of Surgical Research, Fort Sam Houston, TX.
Table 1. ER Capabilitites

 LEVEL IIB LEVEL III

Chest Tubes + +
X-Ray - +
Surgical Airway + +
Ventilations + ++
CRNA + +
Anesthesiologists - +
MEDIC + +
Nurse + ++
PRBCs + +++
Pneumatic Tourniquets - +
Ultrasound + +
ProPaq[R] Monitor + +

Table 2. Operating Room

 Level IIB Level III

Overhead Lighting + ++
Headlamps + ++
Buchwalter Retractor - +
Balfour Retractor + +
Laparotomy Pads + +++
GIA Staplers + +++
Central Line + +
Arterial Line +/- +
Vascular Instruments + ++
Vascular Shunts + +
External Pixators + ++

Table 3. Recovery Room--Postoperative Monitoring

 Level IIB Level III

Swann-Ganz - -
Central Venous Pressure +/- +
Echocardiography - +
Vital Signs/EKG + +
Urine Output + +
Chest X-ray - +
Bronchoscopy - +

POSTOP LABS:

Base Deficit (ISTAT[R]) +/- +
Lactic Acid (ISTAT[R]) +/- +/-
Hematocrit (ISTAT[R]) +/- +
Electrolytes (ISTAT[R]) +/- +
Platelets - +
PT/PTT (ISTAT[R]) +/- +
Thromboelastography - +/-

Table 4. Patient Warning

 Level IIB Level III

Room Temp +/- ++
Thermal Head Cap + +
Baer Hugger[R] +/- +
Fluid Warmer +/- +
Ventilation Warner - +/-
CAVR - +/-

Table 5. Blood Component Availability Comparison

 Level IIB Level III

PRBCs + +++
Whole Blood +/- +++
Fresh Frozen Plasma - +++
Platelets - -
Cryoperecipitate - ++
Factor VIIa +/- ++

Table 6. Surgical Personnel Comparison

 Level IIB Level III

General Surgeons 3 3-7
Vascular +/- +/-
Thoraic +/- 1
Orthopedic 1 2-4
Neurosurgeon - +/-
Urology - 1
ENT - -
OMFS - 1-2

Table 7. Overview Level IIB Versus Level III
Comparison of Capabilities

 Level IIB Level III

Emergency Room + +
Operating Room + ++
Postoperative Care + ++
Hypothermia Prevention +/- ++
Blood & Blood Products +/- +++
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Author:Blackbourne, Lorne H.; Holcomb, John B.
Publication:U.S. Army Medical Department Journal
Date:Apr 1, 2005
Words:2486
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