Overview of Damage Control Operative Intervention

The notion of surgical damage control was originally described in the early 1990s as a means of salvaging severely injured patients or those with dramatic polysystem traumas.  The fundamental underlying tenet of the damage control operation is that definitive surgical intervention is delayed until such a time as the patient has stabilized and adequate resuscitation has been achieved.  It has gained widespread use in Iraq and Afghanistan. 

Major traumatic injuries requiring operative intervention are often associated with the frequently lethal trauma triad of hypothermia, coagulopathy and acidosis.  The triad should be thought of as a feed-forward loop with each component worsening the other two until the patient’s physiologic derangements are such that life is no longer sustainable.

Damage control operative management consists of three phases.  The goals of the first phase are to control bleeding and minimize contamination via rapid surgical interventions.  This may include packing, vessel ligation or shunting, and bowel resection with the patient left in discontinuity, and open abdomen.  The second phase consists of transfer to the trauma ICU for rewarming, ongoing aggressive resuscitation, and the correction of coagulopathy.  The third phase, after adequate resuscitation, and usually within 24-48hours, centers on definitive surgical management of injuries, including organ resection or repair, reestablishing gastrointestinal or vascular continuity, and subsequent closure.  The third phase may involve a staged approach involving several operations. 

Damage control principles have been applied to laparotomy, thoracotomy, peripheral exploration, vascular injuries and orthopaedic trauma. 

Proposed Indications for Damage Control Operation

1.       Core temperature less than 35 degrees Celsius 2.       pH less than 7.2 3.       Base deficit greater than 14mmol/L 4.       Systolic BP persistently less than 80mm/hg 5.       Blood product transfusion requirements greater than 10 units 6.       Estimated blood loss greater than 4L 7.       Intraoperative fluid requirements greater than 10L 8.       Clinical evidence of ongoing coagulopathy (medical bleeding) Consider also: 9.       Life threatening injuries in multiple anatomic locations 10.   Inaccessible vascular injury 11.   Inability to close the abdomen due to edema

 

 post submitted by Dr. Andrew Popoff