Damage control surgery
Section snippets
Historical perspective
Traditional surgical dogma dictates that an operation should be completed definitively regardless of the physiologic condition of the patient. This means that complex reconstructions may be performed in severely compromised patients, resulting ultimately in death. Strategies designed to avoid this inevitable outcome are not new to surgery. Battlefield victims with exsanguinating extremity injuries have undergone rapid amputation for thousands of years. Pringle described compression of liver
The lethal triad
The philosophy of damage control is to abbreviate surgical interventions before the development of irreversible physiologic endpoints. Uncontrolled hemorrhage and iatrogenic interventions ultimately result in the development of hypothermia, coagulopathy, and acidosis. Each of these life-threatening abnormalities exacerbates the others, contributing to a spiraling cycle that rapidly results in death unless hemorrhage is stopped, and the abnormalities reversed. This bloody vicious cycle is
Initial management
The initial management of trauma patients is based on principles described in the Advanced Trauma Life Support course. A systematic evaluation of the patient is performed focusing on treating life-threatening injuries. Patients with life-threatening injuries who require operative intervention are transported to the operating room rapidly. Efforts designed to avoid the lethal triad are implemented throughout this process. The operating room temperature is elevated, and resuscitation fluids are
Complications
Complications following damage control procedures may be related to the site of original injury or to the systemic complications of injury, hemorrhage, massive resuscitation, and infection. Examples of local complications include abscess, fistula formation, intestinal necrosis, and pancreatic pseudocyst. Systemic complications include ARDS and MOF. Massive resuscitation associated with ischemia and reperfusion also results in acute visceral swelling and decreased abdominal compliance,
Summary
Damage control is a staged approach to severely injured patients predicated on treatment priorities. Initially, life-threatening injuries are addressed expediently, and procedures are truncated. Normal physiology is restored in the ICU, and patients subsequently are returned to the operating room for definitive management. This strategy breaks the bloody vicious cycle and results in improved outcomes. Novel technologies like CAVR and rFVIIa contribute to the effectiveness of damage control.
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Cited by (91)
The variable role of damage control laparotomy over 19 years of trauma care in Pennsylvania
2023, Surgery (United States)Citation Excerpt :Standardizing the role of DCL therefore has the potential to limit unnecessary use without adversely affecting mortality, thus minimizing complications and optimizing resource use. There is no doubt that DCL is valuable in severely injured, unstable, trauma patients.3,4,20,21 However, less evidence speaks to the precise indications for its use.
Surgical techniques for damage control operations for abdominal, thoracic, pelvic, and extremity trauma
2023, Current Therapy of Trauma and Surgical Critical CareManagement of Major Vascular Injuries: Neck, Extremities, and Other Things that Bleed
2018, Emergency Medicine Clinics of North AmericaBlood Transfusion Strategies for Hemostatic Resuscitation in Massive Trauma
2016, Nursing Clinics of North AmericaCitation Excerpt :However, as early as 1992, Burch and colleagues19 in a retrospective study of 200 bleeding trauma patients reported more than half the patients died within the first 2 hours of resuscitation after abbreviated laparotomy (damage control surgery), suggesting simple correction of the source of bleeding did not halt exsanguination. Schreiber10 conducted a similar study of damage control surgery to mitigate the effects of the lethal triad and found mortality rates decreased. However, the study concluded two important points.
Advances in Trauma Anesthesia
2016, Advances in AnesthesiaCitation Excerpt :The incidence of coagulopathy in trauma is between 24% and 34% [50–53]. Factors associated with coagulopathy include hypothermia, acidosis, dilution of coagulation factors, consumption of coagulation factors, higher base deficits, hypoperfusion, greater volumes of crystalloid intravenous fluids, tissue damage, inflammation, and injury severity [51,54–60]. Although the coagulopathy of trauma has been characterized using standard hemostasis parameters, such as prothrombin time (PT) and International Normalized Ratio (INR), activated partial thromboplastin time (PTT), platelet count, and fibrinogen levels, there is evidence that these studies do not correlate well with postoperative hemorrhagic complications [61–63].
French surgical experience in the Role 3 Medical Treatment Facility of KaIA (Kabul International Airport, Afghanistan): The place of the orthopedic surgery
2014, Orthopaedics and Traumatology: Surgery and Research