Damage control surgery

Surgical damage control (DCS) is a life-saving series of steps in the critically ill polytrauma patient.

History

 * in the past there was a trend towards a„traditional approach “ - i.e. do everything at once (access, revision, resection, reconstruction) regardless of the patient's condition, but this procedure showedhigh lethality


 * 1983 Stone et al. - principles of DCS
 * 1992 Burch et al. - described the triad of death
 * 1993 Rotondo and Schwab - term DCS
 * 2001 Assensio et al. - intraoperative parameters and indications for starting the DCS protocol

DCS Targets

 * 1) restoration of physiological parameters before anatomical adjustment
 * 2) facilitate control of bleeding and contamination (1. stabilization of fatal problems, 2. resuscitation, 3. definitive treatment)

Triad of Death
1. Hypothermia - consequence of bleeding and resuscitation

Clinical manifestations: ↓ 36°C (if lasting >4h), arrhythmia, suppression of the immune system, systemic vascular resistance

2. Coagulopathy - massive volume resuscitation worsens it with dilution

Clinical manifestations: disorder and inhibition of coagulation factors, platelet dysfunction

Laboratory results are not indicative of hypothermia, only clinical diagnosis (bleeding from wounds, serous surfaces, skin edges)

3. Metabolic acidosis - long-term hypoperfusion → anaerobic metabolism and lactic acidosis

Clinical manifestations: ↓ myocardial contractility, ↓ ejection volume

Indications for DCS
Preoperative parameters


 * 1) high energy injury
 * 2) blunt trauma to the trunk
 * 3) multiple torso injuries
 * 4) hemodynamic instability, coagulopathy and hypothermia on admission

Intraoperative parameters


 * 1) ↓ 34°C
 * 2) pH <7,2
 * 3) HCO3-  <15 mEq/l
 * 4) administration of >5,000 ml transfusions
 * 5) intraoperative replacement > 12,000 ml
 * 6) clinical evidence of intraoperative coagulopathy

Surgical damage control in abdominal injuries
It consists of three successive phases:

1. Phase - abbreviated laparotomy


 * bleeding control and hemostasis (ligatures, clamps, shunts, balloon catheters...)
 * reconstruction is not carried
 * FR abdominal lavage, open abdominal fascia, subcutaneous vacuum drainage

2. Phase - resuscitation in the ICU (modification of the triad of death)


 * hypothermia  - warm infusion solutions, thermal insulation blankets
 * coagulopathy  - ERY meat, Tr concentrate and fresh frozen plasma
 * MAC - adjusts itself by warming the patient

3. Phase - definitive surgical treatment


 * reoperation after 36-48h (vascular reconstruction, GIT continuity)
 * enteral nutrition

Related Articles

 * Injury
 * Rhabdomyolysis
 * Blast syndrome
 * Crush syndrom
 * Compartment syndrome
 * Polytrauma