If this occurs the temporary closure device should be taken down immediately. Of 16 172 patients in the ICRC database, 41% required two operations, 14% three and 20% four or more.2 Serial debridement in this manner is demanding; in mass casualties or resource-poor environments, the ICRC recognises this approach may be impossible and advises wider initial excisions.2. Data would suggest that the longer the abdomen is left open from initial laparotomy the higher the rate of complications. This study demonstrated a 95% patency rate of shunts and an overall survival rate of 88% following major vascular injury. In addition to having the right team in place is having a prepared team. The different variables were systolic blood pressure below 90, hemoglobin <11 g/dL, temperature <35.5, INR > 1.5, base deficit >=6, heart rate >= 120 bpm, presence of penetrating trauma, and positive Focused Abdominal Sonography Trauma (FAST) exam. As the literature begins to grow within the field of damage control surgery, the medical community is continuously learning how to improve the process. The optimization typically takes 24 to 48 hours, depending on how severe the initial insult is. Despite changes in prehospital care and patient transport, open surgical and interventional repair, Conduit other than greater saphenous vein is usually not available or feasible in military or civilian scenarios of, Journal of the American College of Surgeons, International Journal of Surgery Case Reports. Evidence-Based Practice of Critical Care (Third Edition), Surgical Damage Control and Temporary Vascular Shunts, Inferior Vena Cava, Portal, and Mesenteric Venous Systems, Stephanie A. Typically the number of packs has been documented in the initial laparotomy; however, an abdominal radiograph should be taken prior to definitive closure of the fascia to ensure that no retained sponges are left in the abdomen. Certain circumstances might require this, and the patients should continue to receive care from the critical care team during the entire transport period. Adherence to excellent vascular technique with rapid hemorrhage control and limited operative times is the key to success. For the emergency services, truncated scene times and early notification of the receiving hospital trauma team are the priorities; ‘scoop and run’ rather than ‘stay and play’. An attempt should be made to close the abdominal fascia at the first take back, to prevent complications that can result from having an open abdomen. First is hemorrhage control, second is contamination control, third is evaluation or diagnosis, and fourth is reconstruction. Abdominal closure if possible. 18-2). Attention is then turned to performing the necessary bowel anastomosis or other definitive repairs (i.e., vascular injuries). The observations of success-related routing grafts out of or around the zone of injury and contamination (i.e., extraanatomic) should be understood by military surgeons. [7] The U.S. military did not encourage this technique during World War II and the Vietnam War. Damage control-surgery 1. If pelvic bleeding is suspected, the patient may be transferred to the angiography suite at this time. Solid organ injury (i.e., spleen, kidney) should be dealt with by resection. Regardless of which method one decides to use it is important that the abdominal fascia is not reapproximated. If the greater saphenous vein is not available, the lesser saphenous, the cephalic, or the basilic veins should be considered. damage control surgery - guideline triggers 4.1 This guideline will be triggered when there is a need to transfer patients to an operating theatre for DCS to arrest life-threatening haemorrhage, reduce contamination or restore perfusion. These patients clearly have a hernia that must be fixed 9 to 12 months later. In blunt trauma, there is no such evidence. 2013; 656-9. Permissive hypotension is not a new concept, and had been described in penetrating thoracic trauma patients during World War I by Bickell and colleagues demonstrating an improvement in both survival and complications.[11]. In a report from Operation Iraqi Freedom (OIF), Rasmussen et al described a 1-year experience of 126 extremity vascular injuries, in which 30 temporary vascular shunts were utilized in the management of vascular injury. We use cookies to help provide and enhance our service and tailor content and ads. This procedure comprises 5 stages, from temporizing measures to ICU resucitation to definitive surgery and final reconstruction. The intensivist is critical in working with the staff to ensure that the physiologic abnormalities are treated. It can often not be completely controlled by operative surgery, interventional radiology or reduction and fixation of fractures. [17] Subsequent studies were repeated by Feliciano and colleagues,[18] and they found that hepatic packing increased survival by 90%. 4 The three stages were described as mentioned in the subsequent text. Monitor bladder pressure. The core principles of resuscitation involve permissive hypotension, transfusion ratios, and massive transfusion protocol. [5] Minimizing the length of time spent in this phase is essential. The term permissive hypotension refers to maintaining a low blood pressure to mitigate hemorrhage; however, continue providing adequate end-organ perfusion [Duchesene, 2010]. This procedure is generally indicated when a person sustains a severe injury that impairs the ability to maintain homeostasis due to severe hemorrhage leading to metabolic acidosis, hypothermia, and increased coagulopathy. [2][3] Damage control surgery is meant to save lives. Continuous arteriovenous rewarming (CAVR) is occasionally performed when body temperature is less than 35º C. Resuscitation may be guided by early use of a pulmonary artery catheter. Even apparently clean wounds should not be closed before 4–5 days. 1. In their study, the authors used case-controlled methodology to show that the use of temporary vascular shunts had no adverse outcome in the years following vascular repair and likely extended the window for limb salvage, especially in the most severely injured extremities.25 Finally in a recent and larger 10-year review of the civilian experience from Feliciano's group at Grady Memorial, Subramanian et al confirmed the utility of temporary vascular shunts in certain patterns of vascular injury. In these scenarios, exposing and controlling the vascular injury with or without the use of a vascular shunt is accomplished first. It occurs in the pre-hospital setting and continues into the emergency department. [1] This technique places emphasis on preventing the "lethal triad", rather than correcting the anatomy. The main goal this time is to control blood loss and minimizing contamination. If unable to oxygenate with conventinal ventilation, at Parkland Memorial Hospital we use the Volume Diffuse Respirator (VDR) as a salvage therapy. Each of these phases has defined timing and objectives to ensure best outcomes. There are clearly different approaches throughout the country, and no one way is necessarily correct. While typically trauma surgeons are heavily involved in treating such patients, the concept has evolved to other sub-specialty services. Certain pitfalls have also become evident, one of which is the potential to develop abdominal compartment syndrome (ACS). The initial selective nonoperative management of blunt and penetrating abdominal trauma requires the patient to be located in an area where continuous evaluation and monitoring are possible and the eventual transfer to the operating theater is feasible and fast. Nonoperative treatment can be the first-line intervention for stable patients with low- or medium-grade liver, spleen, and kidney injuries. An increase of over 10 would suggest that the abdomen be left open. The bowel should be separated from laparotomy pads. Each injury must be evaluated on a case-by-case basis, as no single algorithm is adequate to predict management in these cases. Typical resuscitation strategies have used an approach where aggressive crystalloid and/or blood product resuscitation is performed to restore blood volume. Savage, Timothy C. Fabian, in. Hypotension is disastrous to an already injured brain, and must not be prolonged by under-resuscitation (see Ch. Gifford and colleagues provided one of the only studies to characterize longer-term extremity outcomes following the use of temporary vascular shunts. The concept Preoperative decision to perform a DCS procedure is frequently made in patients with multisystem trauma. damage control surgery within the combat theater during the acute surgical, postoperative intensive care stabilization, reoperation, and evacuation phases. Damage Control Surgery Brett H. Waibel Michael F. Rotondo I. In this context, one must consider the patient's overall injury pattern and injury severity (i.e., polytrauma) when considering harvest of autologous conduit and vascular reconstruction. Prior to being taken back to the operating room it is paramount that the resolution of acidosis, hypothermia, and coagulopathy has occurred. Restoration of bowel continuity, definitive debridement and wound closure are all deferred until physiology is optimised. As such, the philosophy of damage control continues to be appealing within the realm of CCC, since encompassed within the contingencies of the modern Furthermore, traumatic brain injury is often present in blunt trauma, which frequently involves several body regions. It is important to not only pack areas of injury but also pack areas of surgical dissection. The first is controlling hemorrhage followed by contamination control, abdominal packing, and placement of a temporary closure device. Because of its ease of application, the Vac-Pack dressing allows bedside changes in the intensive care unit. Base deficit >8 mEq/L or worsening base deficit. The authors noted that patency of the shunts hours after placement was higher (86%) when they had been used in larger, more proximal vessel injuries.21 The favorable experience with the use of vascular shunts in this initial report was corroborated by subsequent series provided by other combat surgical teams.22-24 Figures 17-2, A-C detail a case example in which a midsubclavian injury was initially treated at a forward surgical location with the insertion of an intraluminal shunt and subsequently was repaired with interposition graft at a higher level of care. At this point in process the critical care team has been able to correct the physiologic derangements. The leading cause of death among trauma patients remains uncontrolled hemorrhage and accounts for approximately 30–40% of trauma-related deaths. History and Evolution of Damage Control The foundation of damage control surgery (DCS) focuses on exsanguinating truncal trauma. World J Surg. For groups (i.e., trauma centers) to be effective in damage control surgery, a multi-disciplinary team is critical. Vessels that are able to be ligated should, and one should consider shunting other vessels that do not fall into this category. Damage control surgery refers to operations performed in patients whose condition is unstable to control hemorrhage and limit contamination, without completing definitive repair of all injuries. In addition, damage control surgery has been extrapolated for use in general, vascular, cardiac, urologic, and orthopedic surgery. Following massive transfusion exceeding two blood volumes in trauma and emergency surgery, severe physiologic derangement ensued and mortality was found to be greater than 60%. Alicia M. Mohr, ... Allan Capin, in Current Therapy of Trauma and Surgical Critical Care, 2008. How should trauma patients be managed in the intensive care unit? 1998 Dec;22(12):1184-90; discussion 1190-1. A method to pre-emptively evaluate whether fascial closure is appropriate would be to determine the difference in peak airway pressure (PAP) prior to closure and the right after closure. Pringle described this technique in patients with substantial hepatic trauma in the early twentieth century. Early recognition of significant physiologic derangement and the need for DCS are critical as inability to correct pH >7.21 and PTT >70 is associated with near certain mortality. To many, including the editors of this text, the finding of 10 minutes is conservative. DCS is an extreme surgical strategy that should be selectively applied because infection, intraabdominal abscess, wound dehiscence, incisional hernia, and enterocutaneous fistulae are common with its use.17-19, Military experience in Iraq identified a survival benefit in patients receiving a higher ratio of packed red blood cells (PRBCs) to fresh frozen plasma (FFP) and found that they had a significantly lower mortality than patients receiving the lower ratio (19% vs. 65%; p < 0.001).20 This finding has brought about the concept of a balanced or hemostatic resuscitation, where major trauma patients are resuscitated with a unit ratio of around 1 : 1 PRBC to FFP. Then the contralateral saphenous vein is harvested while the fracture is reduced and stabilized. When dealing with hepatic hemorrhage a number of different options exist such as performing a Pringle maneuver that would allow for control of hepatic inflow. From: Critical Care Secrets (Fifth Edition), 2013, Craig Olson MD, Alexander L. Eastman MD, in Parkland Trauma Handbook (Third Edition), 2009. This approach emerged after his observation that early death following trauma was associated with severe metabolic and physiologic derangements following severe exsanguinating injuries. 4. Damage control surgery was described some years ago as abbreviated surgery to stop bleeding and contamination, followed by a period of ICU care before further surgery, to try to arrest the lethal triad of acidosis, hypothermia and coagulopathy.27 US military experience with combat patients is extending this concept to fluid resuscitation as well, with a tendency to give no (or only small amounts of) resuscitation fluids before haemostatic surgery. Rationale for inclusion: Describes the stages and goals of each stage of a damage control surgery for trauma. If massive bleeding resumes, the patient is returned emergently to the operating room for cessation of likely surgical bleeding. Advanced modes of mechanical ventilation may be necessary for patients with packed thoraces. The first step after removing the temporary closure device is to ensure that all abdominal packs are removed. Stage I of damage control surgery is where the patient is taken to the operating theater and undergoes minimal and necessary surgical operations [ 13, 14, 15 ]. [citation needed]. In penetrating trauma, the bleeding is often from single arteries without extensive tissue injury, and complete haemo­stasis can often be easily achieved. Several studies have demonstrated that vein grafts are prone to undergoing transmural necrosis when they are placed in a contaminated field without adequate or viable soft-tissue coverage. Currently, techniques developed by trauma surgeons known as damage control surgery have been successfully used to manage traumatic thoracic, abdominal, extremity, and peripheral vascular injuries. Savage, Timothy C. Fabian, in Rich's Vascular Trauma (Third Edition), 2016. Damage control surgery (DCS) is a technique of surgery used to care for critically ill patients. [23][24] Finally fascial dehiscence has been show to result in 9–25% of patients that have undergone damage control surgery.[25][26]. Michael C Reade, Peter D (Toby) Thomas, in Oh's Intensive Care Manual (Seventh Edition), 2014, The International Committee of the Red Cross (ICRC) recommends as basic principles: early and thorough wound excision and irrigation, no unnecessary dressing changes, delayed primary closure, antibiotics as an adjuvant, antitetanus vaccine and immunoglobulin if necessary, no internal bone fixation, and early physiotherapy.2. [4] The approach would provide a limited surgical intervention to control hemorrhage and contamination. Additionally numerous retrospective studies have shown the effectiveness of vein as a conduit in extremity trauma. The use of temporary vascular shunting and endovascular techniques provide tantalizing glimpses of the ever-evolving management options. Damage control part zero is the earliest phase of the damage control process. The key is to prevent exacerbation of hemorrhaging until definitive vascular control can be achieved, the theory being that if clots have formed within a vessel then increasing the patient's blood pressure might dislodge those established clots resulting in more significant bleeding. DCS consists of a three-phase approach: An initial, nondefinitive, surgical treatment for the control of visceral lesions, hemorrhage, and vascular injuries with simple temporary measures, including stapler intestinal sutures without anastomosis, sponge packing, and vascular shunts using plastic tubes, A resuscitation phase in the intensive care setting, A final definitive surgical intervention once homeostasis is restored. If bowel edema prevents this, several techniques (e.g., Wittman patch) can be employed to help reapproximate fascial edges in stages. Restoration of gastrointestinal and vascular continuity if necessary, Performance of other definitive procedures, such as ostomy placement. When physiologic balance is restored, natural mobilization of third space fluids may be aided with a continuous furosemide drip, titrated to a net negative balance per hour. Ideally performed at 24 to 36 hours, later if indications of physiologic derangement persist, Removal of packs, with replacement if necessary. Daniel J. Scott, Todd E. Rasmussen, in Rich's Vascular Trauma (Third Edition), 2016. Jednalo se tehdy ourgentní laparotomii, která byla prováděna vrámci resuscitační fáze ošetřování polytraumatu. Transfusion with more than 10 units of blood. (Note: Commercially available dressings have been made that accomplish the same goal with less “improvisation” but they are not as cost-effective.). Significant hepatic parenchymal hemorrhage may also be controlled with angiography. The first 24 hours often require a significant amount of resources (i.e., blood products) and investment of time from personnel within the critical care team. Naval War Publications 3-20.31. In using a number of different resuscitation parameters, the critical care team can have a better idea as to which direction is progressing. However, the ability to evaluate objectively the differences and then cho… In detail, they standardized the three stages on which damage control surgery is based presently. It was at this time that hypothermia, acidosis, and coagulopathy were described as the “trauma triangle of death” or the “bloody vicious cycle.” A fourth component, dysrhythmia, which usually heralded the patient's death, was later added by Asensio. Early injury and physiologic pattern recognition Rather than representing a deterioration in technique or care, this likely reflects maintenance and transport of evermore severely injured patients to the hospital phase of management.7 Ongoing changes in resuscitation strategies, with a greater emphasis on matched red blood cell to plasma ratios and decreased crystalloid volumes, may prove especially beneficial in low-pressure venous injuries. [19] This extrapolation allowed for the first article in 1993 by Rotondo and Schwab specifically adapting the term “damage control”. Damage Control Sequence In the beginning, damage control surgery was described by the three main steps: abbreviated laparotomy, ICU resuscitation, and planned re-operation with definitive repair. This should not be attempted in the damage control setting. Delay definitive repair of injury including time-consuming anastomoses and ostomies. Likewise, the open abdomen requires skilled nursing wound care with negative pressure dressings and supplemented nutritional strategies for gastrointestinal drainage and discontinuity. Niten Singh, Reagan W. Quan, in Rich's Vascular Trauma (Third Edition), 2016, Conduit other than greater saphenous vein is usually not available or feasible in military or civilian scenarios of damage control surgery. Presentation Summary : Damage control surgery (DCS) is a form of surgery typically by trauma surgeons utilized in severe unstable injuries. Abdominal packing: packs are inserted into the right upper quadrant, left upper quadrant, and pelvis. This lets granulation occur over a few weeks, with the subsequent ability to place a split-thickness skin graft (STSG) on top for coverage. Damage control surgery (DCS) is an accepted method of minimal surgical management of unstable trauma patients with severe disorders (coagulopathy, hypotension, acidosis, poor response to fluid loading, and large blood losses). This has been seen during implementation of complex processes such as the massive transfusion protocol (MTP). In most experiences, harvesting and preparation of the saphenous vein requires 15 to 30 minutes; and this can be longer if difficulties are encountered with a dual saphenous system or if one includes wound closure in the time estimate. PURPOSE OF REVIEW: Damage control surgery (DCS) has become a lifesaving maneuver for critically injured patients when utilized in appropriate scenarios. [18][19] Next is the development of an entero-atmospheric fistula, which ranges from 2 to 25%. The third step in damage control surgery is addressing closure of the abdomen. Vascular shunting may be employed in extremities using surgical shunts, such as a Javid shunt or large-bore IV tubing. Hematology Am Soc Hematol Educ Program. [7] Surgeons can also apply manual pressure, perform hepatic packing, or even plugging penetrating wounds. Copyright © 2021 Elsevier B.V. or its licensors or contributors. In addition, the description illustrated how the three phases of damage control surgery can be implemented. While this lifesaving method has significantly decreased the morbidity and mortality of critically ill patients, complications can result. This concept has evolved into a coherent strategy incorporating additional hemorrhage control adjuncts and is termed “damage control resuscitation (DCR).”21 Most DCR protocols incorporate techniques such as permissive hypotension, minimal use of crystalloid, aggressive warming, and novel infusible hemostatic drugs such as tranexamic acid paired with damage control surgery for early hemorrhage control.22, Importantly, damage control surgery (DCS) should be considered a tool within DCR, which may be utilized in circumstances of extreme physiology or significant anatomical injury burden.23 The evidence thus far suggests that the adoption of DCR confers a survival advantage, and is associated with a reduction in the use of DCS techniques.18,24,25 However, while DCR demonstrates significant promise, it does liberally utilize precious resources exposing patients to the risks associated with blood products. There are exceptions to the ‘no primary closure’ rule. Instead of replacing blood volume with high volumes of crystalloid and packed red blood cells with the sporadic use of fresh frozen plasma and platelets, we have now learned that maintaining a transfusion ratio of 1:1:1 of plasma to red blood cells to platelets in patients requiring massive transfusion results in improved outcomes [Borgman 2007][1] While this was initially demonstrated in the military setting, Holcomb and colleagues extrapolated this to the civilian trauma center showing improved results as well [12][13] Broad implementation across both the military and civilian sector has demonstrated a decreased mortality in critically injured patients. Eviscerating the intra-abdominal small bowel and packing all four abdominal quadrants usually helps surgeons establish initial hemorrhagic control. Damage Control Surgery in the Treatment of Complicated Diverticulitis (DACSCOD) The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. DEFINITION • Damage control surgery is defined as the rapid initial control of hemorrhage and contamination with packing and temporary closure, followed by resuscitation in the ICU, and subsequent re-exploration and definitive repair once normal physiology has been restored. All the variables were found to be predictive of the need of massive transfusion protocol except for temperature (Callcut 2013). Keen and colleagues reported no graft infections in their population and attributed this success to liberal use of rotational muscle flaps and routing the autologous grafts in an extraanatomic manner out of any contaminated sites.49. DCS is improving overall survival rates and is gaining acceptance among surgeons. The more facile the team is enhances the ability for centers to effectively implement damage control surgery. The following goes through the different phases to illustrate, step by step, how one might approach this. This was the first article that brought together the concept of limiting operative time in these critically ill patients to allow for reversal of physiologic insults to improve survival. Keen reviewed the experience with autologous vein repair in extremity injury (n = 134) in a busy trauma setting and estimated that it required nearly 10 minutes to harvest and prepare the conduit. Moving the patient early on, unless absolutely necessary, can be detrimental. v minulosti bol trend „tradičného prístupu“ - t.z. The benefits of autologous conduit include its familiarity and demonstrated effectiveness in scenarios of elective revascularization for chronic limb ischemia. 75, section on Traumatic brain injury – emergency treatment).24–26. As such, DCR is seen to integrate permissive hypotension, haemostatic resuscitation, and damage control surgery.28 Some enthusiasts are now injudiciously extending DCR to other types of trauma.29 As mentioned above under permissive hypotension, great caution should be exercised before extending this concept to non-exsanguinating blunt trauma, particularly if a traumatic brain injury is present,26 or if remote from a trauma centre. Controlling of hemorrhage as discussed above is the most important step in this phase. The underpinning for damage control is that a traditional operative approach risks physiologic exhaustion, and an abbreviated initial operation controlling only hemorrhage and contamination and … While it might sound counterintuitive since the fascia is left open during the placement of these temporary closure devices, they can create a similar type process that leads to ACS. [8] Once hemorrhage control is achieved one should quickly proceed to controlling intra-abdominal contamination from hollow-viscus organs. Trauma surgery typically has four stages. [9] As mentioned above, it is important to obtain an abdominal radiograph to ensure that no retained sponges are left intra-operatively. Continuous use of convective warming devices (e.g., Bair huggers), Allows “easy access” for planned next operative intervention, At Parkland Memorial Hospital, the “Vac-Pack” dressing is employed by packing the abdomen with laparotomy pads separated from the bowel with a fluid-impervious layer (e.g., a “bogota bag or bowel bag). Damage control surgery can be divided into the following three phases: Initial laparotomy, Intensive Care Unit (ICU) resuscitation, and definitive reconstruction. This description the development of compartment syndrome is a real one only pack areas of surgical.! Technique in patients with low- or medium-grade liver, spleen, and a seal is created over wound!, in Rich 's vascular trauma ( third Edition ), 2020 numerous retrospective studies have shown effectiveness. [ 8 ] Once hemorrhage control and limited operative times is the earliest phase of the of. The vascular injury continue to receive care from the critical care team have. Any physiologic derangements following severe exsanguinating injuries 12 months later ensure that the abdominal fascia not..., Biffl WL, especially trauma patients dangerous “ - t.z possible all. Is essential likely surgical bleeding to which direction is progressing 1993 by Rotondo and Schwab specifically adapting term. Times is the most contaminated wounds procedures for severely injured to damage control surgery stages centers to. Groups ( i.e., spleen, and kidney injuries extremity trauma is disastrous to an already injured brain and. 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