1. DAMAGE CONTROL IN THE PATIENT IN SHOCK: MEDICAL AND SURGICAL THERAPIES
ANA NAVÍO M.D. Ph.D.
EMERGENCY DEPARTMENT, LA PAZ UNIVERSITY HOSPITAL, MADRID, SPAIN

2. IT IS ALWAYS BETTER SMILING

3. 1) HISTORICAL NOTES
2) CURRENT CONCEPTS
3) SO NOW WHAT???

4. # SHOCK is a state of compromised tissue perfusion that causes cellular hypoxia.
# It is a syndrome initiated by ACUTE HYPOPERFUSION, leading to tissue hypoxia and vital organ dysfunction.
# Shock is a SYSTEMIC DISORDER affecting MULTIPLE ORGAN SYSTEMS.
# During shock, PERFUSION IS INSUFFICIENT to meet the metabolic demands of the tissues:
CELLULAR HYPOXIA and end ORGAN DAMAGE .

5. Principle of Medicine:
PRIMUM NON NOCERE
“First do no harm”
Hippocrates

6. “Damage Control Resuscitation represents the most important advance in trauma care for hospitalized civilian and military casualties from this war.”
Cordts, Brosch and Holcomb, J Trauma, 2008

7. His surgical technical was modified by HALSTED in 1913.
The abdominal packing has been the basement for the damage control surgery, and the first phisician (military surgeon) who reported was PRINGLE in 1908.
Pringle JH. Notes on the arrest of hepatic hemorrhage due to trauma. Ann Surg. 1908, 48:541-9.
His surgical technical was modified by HALSTED in 1913.
García-Núñez L, Cabello R, Lever C, Rosales E, Padilla R, Garduño P, et al.
Conceptos Actuales en Cirugía Abdominal de Control de Daños.
Comunicación acerca de donde hacer menos es hacer más. Trauma. 2005; 8:

8. In 1955, MADDING, studied the temporal packing in hemorragic control after abdominal surgery.
The MODERN era of damage-control laparotomy began with the seminal report of STONE ET AL from the Grady Memorial Hospital, Atlanta, Ga, in 1982.
Stone H, Strom P, Mullines R. Management of the major coagulopathy with on set during laparotomy. Ann Surg. 1983; 197:
• The concept of damage control was introduced by ROTONDO y SCHWAB, in patients with dangerous abdominal trauma , described the three times in this surgery.
Rotondo MF, Mc Gonigol MD, Schwab CW, Kauder DR, Hanson CW. Damage Control: An approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma. 1993; 35:375-83

9. New Diagnostic criteria Avoids the “but he looked good” phenomenon
Within the first five minutes in the ED
Identify patients in trouble
Identify patients with increased mortality
Identify patients with increased probability of massive transfusion

11. The CONDUCT OF DAMAGE-CONTROL LAPAROTOMY has been described in detail elsewhere; we can view the process in STAGES.
Germanos S, Gourgiotis S, Villias C, Bertucci M, Dimopoulos N, Salemis N. Damage control surgery in the abdomen: an approach for the management of severe injured patients. Int J Surg Jun;6(3): Epub 2007 May 13
Lee JC, Peitzman AB Nuffield Department of Surgery, John Radcliffe Hospital, Oxford, UK. Damage-control laparotomy.. Department of Surgery, University of Pittsburgh, UPMC-Presbyterian, Pittsburgh, Pennsylvania 15213, USA Curr Opin Crit Care Aug;12(4):

12. The MORE IMPORTANT PHASE is to IDENTIFY the appropriate candidate:
Acidosis- Base Deficit > - 6; ph< 7,2
Coagulopathy : INR > 1.5 or TTPA > 60 sc
Hypotension : Systolic B/P < 90 mmHg
Need of transfusion: > 4 l red cell contents
Temperature : < F=34 C
Pattern recognition
Weak or absent radial pulse
Abnormal mental status
Severe Traumatic Injury

13. The Lethal Triad DEATH COAGULOPATHY HYPOTHERMIA ACIDOSIS
Soto S, Oettinger R, Brousse J, Sánchez G. Cirugía de Control de Daños. Enfrentamiento actual del Trauma. Cuad Cir. 2003;17:

14. The OBJECTIVES are:
1) STOP HEMORRHAGE, to correct underlying coagulopathy,
2) MINIMIZE PERITONEAL CONTAMINATION and its secondary inflammatory response,
3) ENCLOSE THE ABDOMINAL CONTENTS to protect viscera and minimize protein loss.
4) The final objective of this damage-control phase is CLOSURE OF THE ABDOMINAL CAVITY.

15. •Requires robust MEDICAL SETTING
•Need system approach to deliver casualties to MOST CAPABLE FACILITIES
•Isolated and far forward facilities can still benefit from these principles

17. Acidosis
BASE DEFICIT (BD) ≥ -15 identifies patients that require early transfusion, increased ICU days and risk for ARDS and MOF
Ferrara A, Mac Arthur J, Wright H. Hypothermia and Acidosis worsen coagulopathy
in the patient requiring massive transfusion. Ann J Surg. 1990; 160:
BD of ≥ -15 is strongly associated with the need for massive transfusion and mortality in patients.
Rutherford EJ, Morris JA, Reed GW, Hall KS. Base deficit stratifies mortality and determines therapy. J Trauma. 1992; 33:417-23
Patients have an elevated BD before their blood pressure drops to classic “hypotension” levels.
Acidosis contributes more to coagulopathy more than hypothermia (not reversible)

18. Coagulopathy
An initial INR ≥ 1.5 reliably predicts those who will require massive transfusion.
Moore FA, Nelson T. Massive transfusion in trauma patients: tissue hemoglobin oxygen saturation predicts poor outcom. J Trauma 2008 Apr; 64 (4):
Patients who have a significant injury present with a coagulopathy.
Severity of injury and mortality is linearly associated with the degree of the initial coagulopathy.

19. Although resuscitation strategies for severely injured patients who present WITH SHOCK have improved greatly, the transfusions are associated with development of MOF, and increased intensive care unit (ICU) admissions, ICU and hospital length of stay, and mortality
Malone DL, Dunne J, Tracy JK, Putnam AT, Scalea TM, Napolitano LM: Blood transfusion, independent of shock severity, is associated with worse outcome in trauma. J Trauma 2003, 54:
Eastridge BJ, Malone D, Holcomb JB: Early predictors of transfusion and mortality after injury: a review of the data-based literature. J Trauma 2006, 60:S20-S25.
Napolitano L: Cumulative risks of early red blood cell transfusion. J Trauma 2006, 60:S26-S34.
Cotton BA, Guy JS, Morris JA Jr, Abumrad NN: The cellular, metabolic, and systemic consequences of aggressive fluid resuscitation strategies. Shock 2006, 26:

20. Current transfusion practices and survival rates of massive transfusion patients vary widely among trauma centers. Conventional guidelines may underestimate the optimal plasma and platelet to RBC ratios.
Survival in patients is associated with increased plasma and platelet ratios. Massive transfusion practice guidelines should aim for a1:1:1 ratio of plasma: platelets:RBCs.
•Holcomb et al. Ann Surg 2008;248:447

21. Statistical modeling indicated that a clinical guideline with mean plasma: RBC ratio equal to 1:1 would encompass 98% of patients within the optimal 1:2 ratio.
Kaplan-Meier survival plot for the first 24 hours after admission for the 4 groups (high plasma (FFPH) or platelet (PltH) to RBC ratio 1:2, low plasma (FFPL) or platelet (PltL) to RBC ratio 1:2).

22. Hypotension
A systolic blood pressure of 90 mm Hg or less is indicative casualties that have lost over 40% of their blood volume
(~2000 ml in an adult)
They have impending cardiovascular collapse and have significantly increased mortality.

23. The most efficient solution for use in resuscitation is still under debate. Lactated Ringer's (LR) and normal isotonic saline solution (NS) remain the most commonly used isotonic fluids
Although colloid solutions, including hyperosmolar colloid and hypertonic electrolyte compounds, have been approved for use as volume expanders, their administration is still under debate in the USA and Europe.
Moore FA, McKinley BA, Moore EE, Nathens AB, West M, Shapiro MB, Bankey P, Freeman B, Harbrecht BG, Johnson JL, Minei JP, Maier RV: Inflammation and the host response to injury, a large-scale collaborative project: patient-oriented research core: standard operating procedures for clinical care. III. Guidelines for shock resuscitation. J Trauma 2006, 61:82-89.
Spahn DR, Cerny V, Coats TJ, Duranteau J, Fernandez-Mondejar E, Gordini G, Stahel PF, Hunt BJ, Komadina R, Neugebauer E, Ozier Y, Riddez L, Schultz A, Vincent JL, Rossaint R, Task Force for Advanced Bleeding Care in Trauma: Management of bleeding following major trauma: a European guideline. Crit Care 2007, 11:R17

24. Experimental studies have revealed that resuscitation with NS in the setting
of massive hemorrhage requires significantly greater volume and is associated with increased physiologic derangements (for example, hyperchloremic acidosis and dilutional coagulopathy) and higher mortality
as compared with LR
Healey MA, Davis RE, Liu FC, Loomis WH, Hoyt DB: Lactated ringer's is superior to normal
saline in a model of massive hemorrhage and resuscitation. J Trauma 1998, 45:
Todd SR, Malinoski D, Muller PJ, Schreiber MA: Lactated Ringer's is superior to normal saline
in the resuscitation of uncontrolled hemorrhagic shock. J Trauma 2007, 62:
Reported data from several studies conducted in critically ill patients have indicated that use of colloid solutions has a significant impact on hemorrhage , hemostasis, and inflammatory response
Roberts I, Alderson P, Bunn F: Colloids versus crystalloids for fluid resuscitation in
critically ill patients. Cochrane Database Syst Rev 2004, CD
Vercueil A, Grocott MP, Mythen MG: Physiology, pharmacology, and rationale for colloid a
dministration for the maintenance of effective hemodynamic stability in critically ill
patients. Transfus Med Rev 2005, 19:
Lee CC, Chang IJ, Yen ZS: Effect of different resuscitation fluids on cytokine response
in a rat model of hemorrhagic shock. Shock 2005, 24:

25. Early administration of blood is one potential treatment to decrease the need for massive crystalloid solution in hemorrhagic shock; however, the limited supply of stored blood and potential adverse effects make this option logistically difficult and possibly harmful
West MA, Sha piro MB, Nathens AB, Johnson JL, Moore EE, Minei JP, Bankey PE, Freeman B, Harbrecht BG, McKinley BA, Moore FA, Maier RV: Inflammation and the host response to injury, a large-scale collaborative project: patient-oriented research core-standard operating procedures for clinical care. IV. Guidelines for transfusion in the trauma patient. J Trauma 2006, 61:
Moore FA, McKinley BA, Moore EE, Nathens AB, West M, Shapiro MB, Bankey P, Freeman B, Harbrecht BG, Johnson JL, Minei JP, Maier RV: Inflammation and the host response to injury, a large-scale collaborative project: patient-oriented research core: standard operating procedures for clinical care. III. Guidelines for shock resuscitation. J Trauma 2006, 61:82-89.
Spahn DR, Cerny V, Coats TJ, Duranteau J, Fernandez-Mondejar E, Gordini G, Stahel PF, Hunt BJ, Komadina R, Neugebauer E, Ozier Y, Riddez L, Schultz A, Vincent JL, Rossaint R, Task Force for Advanced Bleeding Care in Trauma: Management of bleeding following major trauma: a European guideline. Crit Care 2007, 11:R17.

26. Transfusion-related risks include possible development of MOF, increased ICU admissions and length of stay, increased hospital length of stay, and mortality
Malone DL, Dunne J, Tracy JK, Putnam AT, Scalea TM, Napolitano LM: Blood transfusion, independent of shock severity, is associated with worse outcome in trauma. J Trauma 2003, 54:
Eastridge BJ, Malone D, Holcomb JB: Early predictors of transfusion and mortality after injury: a review of the data-based literature. J Trauma 2006, 60:S20-S25.
Napolitano L: Cumulative risks of early red blood cell transfusion. J Trauma 2006, 60:S26-S34.
Cotton BA, Guy JS, Morris JA Jr, Abumrad NN: The cellular, metabolic, and systemic consequences of aggressive fluid resuscitation strategies. Shock 2006, 26:

27. Risks of Aggressive Volume Resuscitation
↑ hemorrhage + excessive hemodilution due to ↑ Blood Presion, ↓ blood viscosity, ↓ hematocrit, ↓ clotting factor concentration

28. rFVIIa
The use of rFVIIa was associated with improved early and late survival after severe trauma and massive transfusion.
rFVIIa was not associated with increased risk of thrombotic events.
The Effect of Recombinant Activated Factor VII on Mortality in Combat-Related Casualties With Severe Trauma and Massive Transfusion
Philip C. Spinella, MD, Jeremy G. Perkins, MD, Daniel F. McLaughlin, MD, Sarah E. Niles, MD, MPH,Kurt W. Grathwohl, MD, Alec C. Beekley, MD, Jose Salinas, PhD, Sumeru Mehta, MD, Charles E. Wade, PhD,and John B. Holcomb, MD J of Trauma- Feb 2008
Dutton et al. J Trauma 2004;57:709 Conclusion: consider early use of FVIIa in any pt with uncontrolled hemorrhage who has not responded to surgery or blood component therapy

29. Older blood association whith elevates infection, LOS, MOSF + death
Each unit of blood product biologically active + elevates risk of infections + ARDS (SDRA)
Chaiwat et al. Anesthesiology 2009;110:351, n=14,070 pts, NSCOT database, retrospective
Older blood association whith elevates infection, LOS, MOSF + death
Weinberg et al. J Trauma 2008;65:279

30. Temperature
A temperature < 96°F or 35°C is associated with an increase in mortality (cardiac arrest, SRP higher, abnormal plaquelet function)
Burch J, Denton J, Noble R. Physiologic rationale for abbreviated laparotomy. Surg Clin North Am. 1997; 77:
Trauma patients that are hypothermic, are NOT PERFUSING their tissue
The COAGULATION CASCADE is an enzymatic pathway that degrades with temperature and ceases at 92 F
Gregory JS, Francbeum L, Towsened MC. Incidence and timing of hypothermia in trauma patients undergoing operations. J Trauma. 1991; 31:
If the temperature is lower than 33 C, the mortality is 100%,although Beilman and col , think it´s a significant factor for MODS, but not for the mortality.
Beilman GJ, Blondet JJ. Early hypothermia in severely injured trauma patients is a significant risk factor for multiple organ dysfunction syndrome but not mortality. Ann Surg May;249(5):

31. Diagnosis done Damage Control Resuscitation Hypotensive resuscitation
Hemostatic resuscitation

32. Damage control philosophy can be extended to haemostatic resuscitation
Restoring normal coagulation
Minimizing crystalloid
Traditional resuscitation strategies dilute the already deficient coagulation factors and increase multiple organ failure
The aggressive hemostatic resuscitation should be combined with equally aggressive control of bleeding .
Spahn DR, Cerny V. Management of bleeding following major trauma: a European guideline.Crit Care 2007; 11(1): R 17.

33. SURGEON
WAIT AND SEE !!!!

34. ABDOMINAL PACKING is a lifesaving technique for temporary control of severe injury and it is used in damage control surgery schedule.
Its possible too applying packs in organ-specific techniques (early abdominal packing).
The median survival of the 70%, certainly superior to the obtainable survival with immediate surgical repair.
IMMEDIATE FAILURES are substantially due to bleeding, especially in "underpacking" case.
*REMOTE FAILURES : septic and bound at the time of stay (above the 72 hours) and associated by the coexistence of lesions: in these situations is possible a MOF syndrome due to excessive intra-abdominal pressure (overpacking) or to an Abdominal Compartment Syndrome.
Stagnitti F, Bresadola L, Calderale SM, Coletti M, Ribaldi S, Salvi PF, Schillaci F
Abdominal "packing": indications and method. Ann Ital Chir Sep-Oct;74(5):

35. When skin approximation is not possible, a temporary silo is constructed by suturing a 3-L cystoscopy irrigation bag (BOGOTÁ BAG) to the skin edge with a continuous No. 2 nylon suture
. Benavides C, García C, Apablaza S, Rubilar P, Ricaurte F, Perales C, et al. Empaquetamiento hepático permanente con malla de poliglactina en estallido hepático secundario a Síndrome de Hellp. Rev. Chil Cir 2004; 56:
De la Fuente M, Mendoza VH, Robledo-Oyarzun F. Cierre Temporal de la pared abdominal con polietileno. Cir Ciruj 2002; 70: Serna VH. El Síndrome Compartamental Abdominal. Tesis de Postgrado. México

36. The method of closure depends on whether skin approximation produces excessive intra-abdominal hypertension. Towel-clip closure of the skin is preferred because it is quick and easy.

37. WE CAN HEAR THE HEMORRHAGE !!!!
The second phase is intra-operative reassessment for hemorrhage control. 30 minutes after initial abdominal closure in the operating room focusing on restoration of the patient's physiological status, specifically reversing hypothermia and coagulopathy.
WE CAN HEAR THE HEMORRHAGE !!!!

38. The abdomen is then reopened and assessed for adequacy of hemostasis, and for existence of residual mechanical bleeding.
This practice has allowed surgeons to minimize both early return to the operating room for ongoing hemorrhage and the amount of packing necessary for hemostasis.
With bleeding effectively controlled, the abdomen is reclosed.

39. The patient is transferred to the ICU for continued physiologic restoration in the third phase.

40. Once coagulopathy, hypothermia, and acidosis have been corrected, the patient can be returned to the operating room for definitive management of the injuries in the fourth phase.
48-72 h after first surgery

41. COMPLICATIONS OF DAMAGE CONTROL LAPAROTOMY
ACS: Acute Compartmental Syndrome
ARDS: Acute Respiratory Distress of the Adult
MOF: Multiple organ failure
DEATH

42. .
ABDOMINAL COMPARTMENT SYNDROME is defined as an intra-abdominal pressure of greater than 20 cm H2O with evidence of impaired organ function, ie, elevated peak airway pressures (>45 cm H2O), oliguria (<0.5 mL/kg per hour), or cardiovascular dysfunction (hypotension despite adequate volume resuscitation or, if a pulmonary artery catheter is present, oxygen delivery index [calculated as milliliters of oxygen per minute per meter squared] of 600). Intra-abdominal pressure was measured indirectly using an indwelling Foley catheter as previously described.
Int J Surg Jun;6(3): Epub 2007 May 13. Damage control surgery in the abdomen: an approach for the management of severe injured patients.Germanos S, Gourgiotis S, Villias C, Bertucci M, Dimopoulos N, Salemis N
Nuffield Department of Surgery, John Radcliffe Hospital, Oxford, UK.
Curr Opin Crit Care Aug;12(4): Damage-control laparotomy. Lee JC, Peitzman AB. Department of Surgery, University of Pittsburgh, UPMC-Presbyterian, Pittsburgh, Pennsylvania 15213, USA

43. ABDOMINAL COMPARTMENT SYNDROME occurred in 17 (33%) of 52 Patients undergoing damage-control laparotomy and was associated with a much higher incidence of ARDS and MOF (71% vs 31% without ACS; P = .02).
More importantly, our study suggests that primary fascial closure at the termination of the initial damage-control laparotomy contributes to the development of ACS as well as subsequent organ failure.
Ivatury RR, Porter JM, Simon RJ, Islam S, John R, Stahl WM. Intra-abdominal ypertension after life-threatening penetrating abdominal trauma: prophylaxis, incidence, and clinical relevance to gastric mucosal pH and abdominal compartment syndrome. J Trauma. 1998;44:
Mayberry JC, Mullins RJ, Crass RA, Trunkey DD. Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure. Arch Surg. 1997;132:

44. MOF: Multiple organ failure
Seems to be a major source of postinjury morbidity and the leading cause of in-hospital mortality despite more than 25 years of intense investigation.
Eiseman B, Beart R, Norton L. Multiple organ failure. Surg Gynecol Obstet. 1977;144:
Bauer AE, Durham R, Faist E. Systemic inflammatory response syndrome (SIRS), multiple organ dysfunction syndrome (MODS), multiple organ failure (MOF): are we winning the battle? Shock. 1998;10:79-89.
The current pathophysiologic model of MOF focuses on uncontrolled systemic hyperinflammation as a unifying concept following a variety of insults.
Moore FA, Moore EE. Evolving concepts in the pathogenesis of postinjury multiple organ failure. Surg Clin North Am. 1995;75:
Goris RJ, te Boekhorst TP, Nuytinck JK, Gimbrere JS. Multiple-organ failure: generalized autodestructive inflammation? Arch Surg. 1985;120:
Nuytinck HK, Offermans XJ, Kubat K, Goris JA. Whole-body inflammation in trauma patients: an autopsy study. Arch Surg. 1988;123:

45. Examples that improve the prognosis of MOF include damage control surgery, recognition of abdominal compartment syndrome, lung protective ventilation strategies, and tight glucose level control.
Ivatury RR, Porter JM, Simon RJ, Islam S, John R, Stahl WM. Intra-abdominal hypertension after life-threatening penetrating abdominal trauma: prophylaxis, incidence, and clinical relevance to gastric mucosal pH and abdominal compartment syndrome. J Trauma. 1998;44:
The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;342:
Amato MB, Barbas CS, Medeiros DM, et al. Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome. N Engl J Med. 1998;338:
Van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in the critically ill patients. N Engl J Med. 2001;345:

46. The incidence of postinjury MOF has been reported to be between 7% and 66% with an associated mortality rate between 31% and 80%.
Fry DE, Pearlstein L, Fulton RL, Polk HC Jr. Multiple system organ failure: the role of uncontrolled infection. Arch Surg. 1980;115:
Regel G, Lobenhoffer P, Grotz M, Pape HC, Lehmann U, Tscherne H. Treatment results of patients with multiple trauma: an analysis of 3406 cases treated between 1972 and 1991 at a German level I trauma center. J Trauma. 1995;38:70-78.
Sauaia A, Moore FA, Moore EE, Norris JM, Lezotte DC, Hamman RF. Multiple organ failure can be predicted as early as 12 hours after injury. J Trauma. 1998;45:
Nast-Kolb D, Aufmkolk M, Rucholtz S, Obertacke U, Waydhas C. Multiple organ failure still a major cause of morbidity but not mortality in blunt multiple trauma. J Trauma. 2001;51:
Durham RM, Moran JJ, Mazuski JE, Shapiro MJ, Baue AE, Flint LM. Multiple organ failure in trauma patients. J Trauma. 2003;55:

47. It has been suggested that MOF is disappearing owing to advances in trauma and critical care
Levine JH, Durham RM, Moran J, Bauer A. Multiple organ failure: is it disappearing? World J Surg. 1996;20:
Recent reports have not demonstrated a consistent change in either the incidence or the mortality rate associated with postinjury MOF.
Some groups have reported no change in the incidence but a decreased mortality while others have reported both decreased incidence and mortality compared with historical control subjects.
Durham RM, Moran JJ, Mazuski JE, Shapiro MJ, Bauer AE, Flint LM. Multiple organ failure in trauma patients. J Trauma. 2003;55:
Regel G, Grotz M, Weltner T, Sturm JA, Tscherne H. Pattern of organ failure following
severe trauma. World J Surg. 1996;20:

51. Orthopaedic Trauma

52. Open pelvic fractures in addition to the pelvic ring injury are associated with hemorrhage and neurological insult, visceral injuries are more common, and a high rate of infection is seen.
Mortality of open pelvic fractures historically approached 50%.
Control of bleeding is the most important initial measure, followed by debridement and packing of open wounds.
Type 1 fractures occur due to anterior-posterior
compression;can cause the symphysis pubis to
“pop” open, leading to pubic rami, or “open book”
fractures. A lateral compression fracture
type 2, or vertical sheer facture (Type 3) can also
lead to severe bleeding Into the pelvis.
Pelvic and acetabular surgery are major
surgical interventions.
Open book- widened symphysis pubis. Dislocated Rt SI joint. Vallier + Jenkins. In: Trauma Anesthesia. 2008

53. Figura 1.- Aplicación de la engrapadora para la resección pulmonar en cuña. Los segmentos a resecar se limitan por medio de la aplicación de dispositivos de grapado orientados en direcciones perpendiculares, tratando de mantener la mayor cantidad de tejido sano.
Inserción de engrapadora lineal cortante a través de los orificios del tracto de la herida pulmonar penetrante.

54. Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y vías aéreas distales
Figura 3.- Apertura del tracto de la herida pulmonar penetrante y ligadura de vasos sangrantes y vías aéreas distales con fuga aérea visible.

55. Aplicación de un DGQ lineal en el hilio pulmonar, durante una Toracotomía en el Salón de Operaciones. El pulmón derecho se retrajo cefálicamente de forma manual.
Imagen en la cual se demuestra la discontinuidad del tracto gastrointestinal, tras el grapado y resección del asa

56. Figura 6.- Fotografía del mismo paciente, en donde se observa la línea de grapas en el hilio pulmonar derecho.
Figura 7.- Aplicación de una engrapadora lineal cortante para resecar un segmento intestinal desvitalizado. El tracto gastrointestinal se dejó en discontinuidad.

57. Grapa metálica aplicada con Ligaclip MCA, Multiple Clip Applier (Ethicon Endosurgery, Somerville, NJ, US) en un vaso sanguíneo individual en el interior del parénquima hepático, durante una técnica de CCD.
Aplicación de la prótesis de la pared abdominal (bolsa plástica de solución intravenosa), asegurándola a la piel con engrapadoras apropiadas.

58. Trauma team training is an invaluable part of trauma care in any trauma organitation.
The retroperitoneal packing training sessions have aided in developing professional multidisciplinary teamwork in real trauma situations. Emphasis has been placed on the importance on clearly communicating the background of broadly accepted guidelines
However, some specific surgical procedures need to be taught either in real situations or on corpses.
Clinical research is an important factor in improving survival after critical incidences; however, it cannot stand alone.
A new concept, 'Formula of Survival', has emphasised the importance of education and implementation of new knowledge into clinical practise
Therefore, education and implementation have been a focus for developing our trauma organisation.

59. THANKS FOR YOUR ATTENTION
LET´S TAKE A DRINK, IN VALENCIA!!