Once the endovascular team is available, the surgeon and radiologists can work together to combine operative and endovascular interventions to stop bleeding. Damage control Laparotomy 18 Principles • Control haemorrhage operative control of haemorrhage and simultaneous vigorous resuscitation with blood and clotting factors Availability of Blood, FFP, cryoprecipitate, platelet • Prevention contamination • Avoid further injury • Evacuation of blood. Lakstein D, Blumenfeld A, Sokolov T, Lin G, Bssorai R, Lynn M, et al. Bladder pressures should be measured frequently or even continuously. Compressible hemorrhage sites are amenable to direct digital pressure or tourniquet control, which can be instituted by first responders. J Orthop Trauma. The principles of damage control surgery were first described by Stone et al in 1983 in an attempt to reduce mortality in exsanguinating patients with coagulapathy. The impact of hypoxia and hyperventilation on outcome after paramedic rapid sequence intubation of severely head-injured patients. Prehosp Emerg Care. The use of spanning external fixation, antibiotic bead pouches 118 - 120 ( Figs. Advanced burn life support manual. Damage control surgery. It may take time to move another patient out of an ICU room, clean the room, and bring the hospital bed to the operating room. 2008;64:S38–49. Generally, the trauma patient is supine with both arms abducted at 90° and prepped from chin to knees and laterally to the bed. be prevented using damage control principles rather than attempting to treat it once it has occurred. When proceeding to the operating room, the staff should be told to obtain a sterile pneumatic tourniquet and prepare for abdominal and extremity exploration and temporary dressings. In abdominal surgery, “damage control” refers to those maneuvers designed to ensure patient survival. Practical use of emergency tourniquets to stop bleeding in major limb trauma. If these goals are met, isotonic crystalloid may be used, but be mindful that normal saline may lead to a non-anion gas metabolic acidosis, worsening coagulopathy. Damage control surgery involves limited surgical interventions to control haemorrhage and minimize contamination until the patient has sufficient physiological reserve to undergo definitive interventions. Early injury and physiologic pattern recognition Damage control surgery aims to stop haemorrhage, restore blood flow and control wound contamination. Damage control surgery can be divided into the following three phases: Initial laparotomy, Intensive Care Unit (ICU) resuscitation, and definitive reconstruction. Blast injuries can create penetrating wounds from shrapnel, but can throw a patient with great force, causing blunt injuries as well. Liver and lung resections are non-anatomical and usually performed with staplers. The role of secondary brain injury in determining outcome from severe head trauma. Krishna G, Sleigh JW, Rahman H. Physiological predictors of death in exsanguinating trauma patients undergoing conventional trauma surgery. Bleeding organs on a pedicle (spleen, kidney) should ideally be sacrificed. J Trauma. Davis DP, Hoyt DB, Ochs M, Fortlage D, Holbrook T, Marshall LK, et al. Damage control surgery refers to limited surgical interventions that serve to control haemorrhage and minimize contamination until the patient has sufficient physiological reserve to undergo definitive interventions. J Neurosurg. If there is a possibility the patient may be proceeding to the operating room, notifying the operating room team at the earliest opportunity is ideal. damage control Morgan K, Mansker D, Adams DB. Improved survival following massive transfusion in patients who have undergone trauma. Purpose of review Damage control surgery (DCS) has become a lifesaving maneuver for critically injured patients when utilized in appropriate scenarios. Neurocrit Care. References. 2010;252:959–65. Acute respiratory distress syndrome (ARDS) and transfusion-related acute lung injury (TRALI) can result from aggressive resuscitation and blood product administration. Finally, complications of resuscitation can arise. Kragh Jr JF, Baer DG, Walters TJ. Cricothyroidotomy may be necessary with a blast to the face. 4. Damage control concepts and techniques have been part of our clinical armamentarium in trauma and emergency surgery for decades. 1993;35:375–82. Endotracheal intubation in the field does not improve outcome in trauma patients who present without an acutely lethal traumatic brain injury. J Trauma. Extending the horizons of “Damage Control” in unstable trauma patients beyond the abdomen and gastrointestinal tract. Bernard SA, Nguyen V, Cameron P, Masci K, Fitzgerald M, Cooper DJ, et al. © 2020 Springer Nature Switzerland AG. In some instances, time will only permit splash prep. In addition to the trauma, hemorrhage and tissue hypoperfusion, a secondary systemic injury, by inflammatory mediator release, contributes to acidosis, coagulopathy, and hypothermia and leads to multi system organ failure. Despite this reality, indications for initiating DCS remain debated. Chicago, IL: American Burn Association; 2010. 2.4k Downloads; Abstract. The principles of damage control surgery were applied in the cases of three severely injured multitrauma patients, men aged 47 and 33 years who had a motorcycle accident and a 66-year-old man who had a car crash. Depending on patient stability and resource availability, the team may elect to obtain a CT to gain further information. The goal of Part 2 is to continue aggressive resuscitation in a rapid fashion in order to correct the physiologic derangements. PURPOSE OF REVIEW: Damage control surgery (DCS) has become a lifesaving maneuver for critically injured patients when utilized in appropriate scenarios. Previously, 2 l of isotonic crystalloid were given followed by either more crystalloid or blood products if available to achieve a desired response in vital signs. Epidemiology, severity classification, and outcome of moderate and severe traumatic brain injury: a prospective multicenter study. A clinical series of resuscitative endovascular balloon occlusion of the aorta for hemorrhage control and resuscitation. Report can be called about 20–30 min prior to leaving the operating room which allows the ICU staff time to set up suctioning, warming, and massive transfusion equipment, gather pumps, tubing and supplies, and prepare for the patient as well as notify respiratory therapy to bring a ventilator to the ICU room. J Trauma. J Trauma. ... is the most common indication for damage control surgery. 157 Accesses. Tourniquet use in combat trauma: UK military experience. Extremity vascular injuries on the battlefield: tips for surgeons deploying to war. Other situations that lend themselves to damage control are those where endovascular techniques may achieve hemorrhage control more effectively such as severe liver or pelvic bleeding. The principles of damage control surgery are ; Control haemorrhage ; Prevention contamination ; Avoid further injury; 12. Damage control resuscitation (DCR) is a strategy for resuscitating patients from hemorrhagic shock to rapidly restore homeostasis. Brenner ML, Moore LJ, DuBose JJ, Tyson GH, McNutt MK, Albarado RP, et al. Guidelines for prehospital management of traumatic brain injury, 2nd edn. If at any point during Part 2 the acidosis or coagulopathy is not correcting or was trending in the correct direction, but then regresses, or if there is clinical evidence of ongoing, rapid hemorrhage, the patient should be immediately returned to the operating room as this is indicative of a missed injury or ongoing, uncontrolled bleeding. Damage control surgery (DCS) is a concept of abbreviated laparotomy, designed to prioritize short-term physiological recovery over anatomical reconstruction in the seriously injured and compromised patient. The ipsilateral arm is abducted at 90° and elbow flexed at 30°. 2018 Apr;42(4):965-973. J Trauma. J Trauma. 4. Serial troponins and electrocardiograms may also be included. For example, a patient with a thoracoabdominal injury or multiple stab wounds may need both the abdomen and mediastinum or thorax explored, and the surgeon must make a judgment about which cavity is the primary source of bleeding or life-threatening injury. 1999;25:805–13. Fractures can be splinted to provide stability and decrease ongoing bleeding. Damage control with the blast-injured patients is done in large part by controlling hemorrhage. Ultrasound can help guide resuscitation, as intravascular volume can be based on inferior vena cava (IVC) collapsibility and cardiac contraction. The blood bank can be notified if a massive transfusion is planned in order to begin thawing products. The replacement of lost and consumed coagulation factors was the mainstay in the resuscitation of hemorrhagic shock for many decades. Supply carts and medication dispensers/storage should be in close proximity if not in the same room along the walls. The principles of damage control surgery in trauma care include abbreviated surgery to control blood loss and contamination in the abdomen, simultaneous resuscitation of physiology, and definitive surgical management at a later stage after restoration of … Radiology technicians can be at the bedside waiting with portable X-rays and can expedite any other radiological interventions such as computed tomography (CT). Basic principles of damage control surgery Definition of damage control surgery. Core temperature should be monitored and rewarming measures such as blankets and warmed fluids used because hypothermia can inactivate the clotting cascade and impede the body’s ability to coagulate blood. Damage control surgery for non-traumatic abdominal emergencies. Brain Trauma Foundation. Part of Springer Nature. Management of these cases has changed significantly in the last decade with the emergence of a new paradigm termed damage control. Compartment syndrome may develop in the abdomen even with a temporary dressing in place. 2003;54:307–11. There are two goals in damage control Part 1: control of bleeding and contamination. 2006;61:824–30. [toc] Question 20 from the first paper of 2011 and Question 21 from the second paper of 2008 discuss the principles of damage control surgery in trauma, the practice of repairing lifethreatening injuries quickly, and leaving the definitive management until physiological normality is restored.. Porter JM, Ivatury RR, Nassoura ZE. J Trauma. Hemorrhage is the leading cause of preventable death on the battlefield. INTRODUCTION 9 introduction Facing the challenges One night while on duty Dr X, an experienced surgeon working in an ICRC field … N C Med J. Chambers LW, Green DJ, Sample K, Gillingham BL, Rhee P, Brown C, et al. If at any point the patient becomes hemodynamically unstable or physiologically deranged as in Part 1, begins re-bleeding, or demonstrates they are unable to undergo a lengthy operation, the temporary dressing may be reapplied and the patient returned to the ICU for further resuscitation. Most vessels may be ligated. 1996;40:764–7. A recent review by Shapiro et al identified over 1000 trauma patients who were treated using these modern techniques [8]. Spinal stabilization often helps to prevent further damage. This is a preview of subscription content. Not logged in J Trauma. In extreme situations, intubation may be occurring while prepping and draping the patient. Damage control surgery (DCS) is a concept of abbreviated laparotomy, designed to prioritize short-term physiological recovery over anatomical reconstruction in the seriously injured and compromised patient. 1. Patients with multiple cavity injuries are ideal candidates for damage control. Holcomb JB. Damage Control Surgery (DCS) is an operative strategy that sacrifices the completeness of the immediate surgical repair in order to address the physiological consequences of the combined trauma of the injury and surgery. 2003;54:S221–5. Prehosp Emerg Care. The term “damage control” refers to a specific approach to the exsanguinating trauma patient. NTLHE. Patients with non-compressible hemorrhage sources receive the highest priority for immediate transport to a hospital. Scand J Surg. • Full exposure of the injuries. Finally, the massive transfusion protocol should be implemented as soon as deemed necessary to ensure products are available as soon as possible whether it be in the ICU or operating room. Holcomb JB, Helling TS, Hirschberg A. Introduction Damage control surgery (DCS ) has been the standard of care for the last 20 years in multiple trauma patients(all cutting disciplines) Necessitated by excessive haemorrhage and high mortality from total care Damage Control … 1993;34:216–22. 159.89.172.72. Aust N Z J Surg. This surgery should follow DCS principles and may include surgery for proximal haemorrhage Part 2 occurs in the ICU. The Westmead Head Injury Project outcome in severe head injury. Brown CV, Rhee P, Chan L, Evans K, Demetriades D, Velmahos GC. Prehospital tourniquet use in operation Iraqi freedom: effect on hemorrhage control and outcomes. Emergency medical services (EMS) can communicate valuable information prior to patient arrival, such as prehospital hypotension, hypothermia, blood loss, and ongoing hemorrhage that can trigger the trauma team to entertain damage control. Tourniquet use on the battlefield. Surg Clin N Am. 2002;91:92–103. There are clearly different approaches throughout the country, and no one way is necessarily correct. Arch Surg. If a vessel supplies an end organ or extremity, the vessel should be shunted [. Damage control surgery. J Trauma. Damage Control Resuscitation (DCR) works synergistically with Damage Control Surgery (DCS) and prioritizes non-surgical interventions that reduce morbidity and mortality due to trauma and hemorrhage. pp 99-108 | The principles of trauma surgery have evolved during the past 20 years; from initial aggressive, definitive management of all surgical injuries in the traumatised patient to an abbreviated laparotomy, secondary correction of abnormal physiological parameters and then planned definitive re-exploration; the damage control sequence. Ann Surg. 2003;54:444–53. J Trauma. Authors; Authors and affiliations; Fredric M. Pieracci; Ernest E. Moore; Chapter. The characteristic of the output from the temporary vacuum dressing and the amounts from the drains and tubes should be monitored. Examiner should be on patient’s left side to facilitate Emergency Department (ED) thoracotomy and other surgical procedures if necessary. Note that the Recorder is adjacent to the Team Leader to read back information. Victims of major trauma suffer from a worsening physiologic derangement manifested by the triad of acidosis, hypothermia and coagulopathy. J Neurotrauma. If a combined thoracotomy and laparotomy is entertained and the hemithorax previously determined, a modified taxi cab hailing position is ideal. Kragh Jr JF, Walters TJ, Baer DG, Fox CJ, Wade CE, Salinas J, et al. Brodie S, Hodgetts TJ, Ollerton J, McLeod J, Lambert P, Mahoney P, et al. Tactical surgical intervention with temporary shunting of peripheral vascular trauma sustained during operation Iraqi freedom: one unit’s experience. Davis DP, Dunford JV, Ochs M, Park K, Hoyt DB. [1–25] Damage control resuscitation seeks to minimize blood loss until definitive hemostasis is achieved. The patient is primarily supine, but on the ipsilateral side of the thorax to be entered, the chest wall is rotated medially about 30° to the coronal plane and supported with a roll. Bochicchio GV, Ilahi O, Joshi M, Bochicchio K, Scalea TM. Mil Med. China: Elsevier, Inc.; 2012. Despite this reality, indications for initiating DCS remain debated. Military, civilian, and rural application of the damage control philosophy. Gettings LG, Reynolds HN, Scalea T. Outcome in post-traumatic acute renal failure when continuous renal replacement therapy is applied early vs. late. 2006;86:711–26. Once the patient is resuscitated as defined by meeting end-organ and hemodynamic endpoints, the patient is returned to the operating room for definitive repair. Field hypotension in patients who arrive at the hospital normotensive: a marker of severe injury or crying wolf? Author information: (1)Department of Surgery, Division of Trauma/Critical Care, University of South Alabama Medical Center, Mobile, AL 36617, USA. If a vascular injury is suspected, both legs from the inguinal ligament to knees should be prepped in case vein graft is needed. Pape HC, Giannoudis P, Krettek C. The timing of fracture treatment in polytrauma patients: relevance of damage control orthopedic surgery. Damage control surgery and resuscitation is the concept of abbreviating interventions in severely injured patients to prevent physiologic exhaustion and optimize outcome. BACKGROUND. Twenty years ago, damage control surgery (DCS) was implemented to challenge the coagulopathy of trauma. The following goes through the different phases to illustrate, step by step, how one might approach this. The principles of damage control surgery and resuscitationlisted below are of tantamount importance for the care of the patientwho is hypothermic, coagulopathic, acidotic, and resistant to fluidresuscitation. All exsanguination must be expeditiously stopped. Stone HH, Strom PR, Mullins RJ. Starnes BW, Beekley AC, Sebesta JA, Anderson CA, Rush Jr RM. 2013;75:506–11. In recent years, the damage control concept has expanded to other surgical disciplines: emergency general surgery, orthopedics, thoracic, vascular, etc. Angiography before damage control laparotomy may also be indicated if there is The LITFL page on damage control surgery is an excellent introduction to the subject. Damage control surgery is defined as rapid termination of an operation after ... Damage control principles can be applied to all disciplines of trauma care. Reilly PM, Rotondo MF, Carpenter JP, Sherr SA, Schwab CW. IATSIC itself has 270 members in 53 countries, distributed on every continent. Using large stacks of gauze or additional dressings in lieu of manual compression should be avoided, as this technique dissipates the pressure applied directly to the bleeding site and may delay identification of ongoing bleeding [, While use of tourniquets has been controversial in the damage control situation, multiple reports in the literature of tourniquet use have defined their advantages [. The trauma laparotomy should be performed in a routine, systematic manner, minimizing the likelihood of missed injuries. Blast injuries are challenging as patients can suffer from both penetrating and blunt mechanisms. If the patient’s bleeding is controlled upon arrival, the primary and secondary surveys should be rapidly conducted in the usual fashion, and the four remaining cavities assessed for hemorrhage with the usual adjuncts. J Trauma. If multiple cavities are left open in Part 1, all cavities may be closed in Part 3 or only one and Part 3 repeated for each cavity. This webinar aimed at medical undergraduates will provide an outline of the principles and practice of damage control resuscitation and surgery. There are two goals in damage control Part 1: control of bleeding and contamination. Necessary equipment can be gathered and procedure trays opened. 2010;69:294–301. Parts 1 and 2 may be repeated multiple times over several days to a week prior to Part 3 definitive repair. Eiseman B, Moore EE, Meldrum DR, Raeburn C. Feasibility of damage control surgery in the management of military combat casualties. hphela@yahoo.com PMID: 17116562 [Indexed for MEDLINE] Most importantly, roles during the triage are assigned and performed in an organized manner. For extremities, a Stryker needle can be used to objectively quantify the pressure; rapid, significant increases in compartment pressures, a measured compartment pressure >30 mmHg, or <30 mmHg difference in the diastolic blood pressure and measured compartment pressure should prompt fasciotomies. Once bleeding is controlled in one cavity, the surgeon must rapidly examine the next. 1998;68:826–9. Once a cavity is opened, hematoma and blood should be evacuated (usually manually) and the cavity packed with lap sponges. Int Care Med. Phelan HA(1), Patterson SG, Hassan MO, Gonzalez RP, Rodning CB. 2011;28:2019–31. Patient selection also plays a role; the elderly, those with more comorbidities, and pediatric patients have less reserve, and thus, the team should have a lower threshold for damage control. 2011;71:1869–72. 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 reexploration and Stein SC, Georgoff P, Meghan S, Mizra K, Sonnad SS. Since endovascular technology has further evolved, the use of resuscitative endovascular balloon occlusion of the aorta (REBOA) in trauma is being revisited [. This strategy was derived from military experience and is now increasingly adopted into civilian trauma management. Various maneuvers (Kocher, Mattox, Cattell-Braasch) expose the retroperitoneum. Chad G. Ball 1, Camilo Correa-Gallego 1, Thomas J. Howard 1, Nicholas J. Zyromski 1 & Keith D. Lillemoe 1 Journal of Gastrointestinal Surgery volume 14, pages 1632 – 1633 (2010)Cite this article. Initially, the DCS has been described in severe liver trauma associated with coagulopathy. 2007;62:S36–7. 1997;42:559–61. 2000;135:1323–7. This often leads to a vicious cycle … Hoey BA, Schwab CW. While the resuscitation ratio is debated, a 1:1 or 1:2 ratio of packed red blood cells (pRBCs) to fresh frozen plasma (FFP) is the current recommendation. Zeiler FA, Teitelbaum J, West M, Gillman LM. Over the last 10 yr, a new addition to the damage control paradigm has emerged, referred to a … A critical judgment to be made by the surgeon is that of the operative profile: damage control versus definitive repair. Damage control surgery has been performed for a wide range of indications, but most frequently for uncontrolled bleeding during elective surgery, haemorrhage from complicated gastroduodenal ulcer disease, generalized peritonitis, acute mesenteric ischaemia and other sources of intra-abdominal sepsis. 1 damage control resuscitation (DCR) emerged as an extension of a principle used by trauma surgeons called damage control surgery (DCS), which limits surgical interventions to those which address life-threatening injuries and delays all other surgical care until metabolic and physiologic derangements have been treated. Damage control surgery and resuscitation is the concept of abbreviating interventions in severely injured patients to prevent physiologic exhaustion and optimize outcome. 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.