Bowel injuries may be quickly closed or resected with stapled ends left in discontinuity. There are various methods that can be used to pack the abdomen. Damage control surgery mandates the first two stages but defers the third … DCS is improving overall survival rates and is gaining acceptance among surgeons. This has been seen during implementation of complex processes such as the massive transfusion protocol (MTP). Savage, Timothy C. Fabian, in. Damage control surgery, DCS, Abdominal compartment syndrome, ACS It is important to not only pack areas of injury but also pack areas of surgical dissection. Controlling of hemorrhage as discussed above is the most important step in this phase. 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. Initial resuscitation of trauma patients continues to evolve. In this regard, it is paramount that ICUs specializing in the care of trauma patients be familiar with management of severe biomechanical and physiologic derangements that occur as chest and abdominal wall geometry are altered. Gifford and colleagues provided one of the only studies to characterize longer-term extremity outcomes following the use of temporary vascular shunts. Damage control surgery (DCS) is divided into four distinctive stages: the decision to perform DCS, the operation, intensive care unit resuscitation, and second-look/definitive operation. In addition, damage control surgery has been extrapolated for use in general, vascular, cardiac, urologic, and orthopedic surgery. Alicia M. Mohr, ... Allan Capin, in Current Therapy of Trauma and Surgical Critical Care, 2008. All the variables were found to be predictive of the need of massive transfusion protocol except for temperature (Callcut 2013). [19] This extrapolation allowed for the first article in 1993 by Rotondo and Schwab specifically adapting the term “damage control”. Surface Ship Survivability. 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 approach emerged after his observation that early death following trauma was associated with severe metabolic and physiologic derangements following severe exsanguinating injuries. 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 … [citation needed]. This specifically relates to factors such as acidosis, coagulopathy, and hypothermia (lethal triad) that many of these critically ill patients develop. [21], There are four main complications. [7] The U.S. military did not encourage this technique during World War II and the Vietnam War. Although it may be defined as "limited operation for control of hemorrhage and contamination", a number of techniques based on a good deal of experience are now used in a variety of situations. 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. Preoperative decision to perform a DCS procedure is frequently made in patients with multisystem trauma. "V. Notes on the Arrest of Hepatic Hemorrhage Due to Trauma", "The Prospective, Observational, Multicenter, Major Trauma Transfusion (PROMMTT) Study", "Defining when to initiate massive transfusion", "Creation, Implementation, and Maturation of a Massive Transfusion Protocol for the Exsanguinating Trauma Patient", "Management of the major coagulopathy with onset during laparotomy", "Abbreviated laparotomy and planned reoperation for critically injured patients", Trauma.org - Damage Control Surgery overview, Focused assessment with sonography for trauma, https://en.wikipedia.org/w/index.php?title=Damage_control_surgery&oldid=992951101, Articles with unsourced statements from December 2015, Creative Commons Attribution-ShareAlike License. The goal of DCS is a short operating time, followed by transport to an intensive care unit. 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. This should not be attempted in the damage control setting. Transfusion with more than 10 units of blood. Certain pitfalls have also become evident, one of which is the potential to develop abdominal compartment syndrome (ACS). 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). Massive transfusion (defined as receiving greater than or equal to 10 units of packed red blood cells with a 24-hour period) is required in up to 5% of civilian trauma patients that arrive severely injured. In addition to having the right team in place is having a prepared team. 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. This is referred to by some as damage control ground zero (DC0). Bailout/damage control surgery following trauma has developed as a major advance in surgical practice in the last 20 years. Most of the time, circumstances such as patient positioning, other injuries, or indwelling intravenous lines exclude exposure and procurement of these alternative vein conduits. The head, neck and genitals have such good blood supply that primary closure is possible in all but the most contaminated wounds. First is hemorrhage control, second is contamination control, third is evaluation or diagnosis, and fourth is reconstruction. Listing a study does not mean it has been evaluated by the U.S. Federal Government. We use cookies to help provide and enhance our service and tailor content and ads. História [upravit | editovat zdroj]. The final step of this phase is applying a temporary closure device. A. This typically requires close monitoring in the intensive care unit, ventilator support, laboratory monitoring of resuscitation parameters (i.e., lactate). [20] This term was taken from the United States Navy who initially used the term as “the capacity of a ship to absorb damage and maintain mission integrity” (DOD 1996). Staged physiologic restoration and damage control surgery. Their initial study showed a 58% overall survival, which increased to 77% in selected population (major vascular injury with two or more visceral injuries). There are clearly different approaches throughout the country, and no one way is necessarily correct. [16] New ways of measuring coagulopathy such at thromboelstography (TEG) and rotational thromboelastometry (ROTEM) have allowed for a more robust assessment of the coagulation cascade compared to traditional methods of measuring international normalized ratio (INR) allowing clinicians to better target areas of deficiency. 2 Definition; History; The Lethal triad; Stages of damage control surgery; Damage Control Orthopedics; Complications of Damage Control… Monitor bladder pressure. The following goes through the different phases to illustrate, step by step, how one might approach this. Massimo Antonelli, ... Anselmo Caricato, in Clinical Critical Care Medicine, 2006. As previously discussed, damage-control surgery involves a follow-up phase in which the abdomen is re-explored and definitive procedures may be performed, for example, bowel anastomosis, packing removed, and so on. Advanced modes of mechanical ventilation may be necessary for patients with packed thoraces. Ideally performed at 24 to 36 hours, later if indications of physiologic derangement persist, Removal of packs, with replacement if necessary. The patients that received a higher ratio had an associated three to four-fold decrease in mortality. The bowel should be separated from laparotomy pads. Each of these phases has defined timing and objectives to ensure best outcomes. In contrast, in blunt trauma, the bleeding is often venous as well as arterial, with capillary oozing into the soft tissues, which may continue for hours. If bowel edema prevents this, several techniques (e.g., Wittman patch) can be employed to help reapproximate fascial edges in stages. Ligation of named vascular structures may be necessary and/or temporary vascular clamps may be used. In detail, they standardized the three stages on which damage control surgery is based presently. Damage control surgery can be divided into the following three phases: Initial laparotomy, Intensive Care Unit (ICU) resuscitation, and definitive reconstruction. Damage control surgery can be divided into the following three phases: Initial laparotomy, Intensive Care Unit (ICU) resuscitation, and definitive reconstruction. The third step in damage control surgery is addressing closure of the abdomen. In this setting, the conduit can degrade or break down because of bacterial contaminated with or without desiccation of the main body of the graft or the anastomotic sites. A multi-disciplinary group of individuals is required: nurses, respiratory therapist, surgical-medicine intensivists, blood bank personnel and others. Oral mucosa should always be closed primarily if possible. The Three stages of damage control are as follows: Control of hemorrhage and contamination. This lets granulation occur over a few weeks, with the subsequent ability to place a split-thickness skin graft (STSG) on top for coverage. The core principles of resuscitation involve permissive hypotension, transfusion ratios, and massive transfusion protocol. Restoration of bowel continuity, definitive debridement and wound closure are all deferred until physiology is optimised. 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. Pringle described this technique in patients with substantial hepatic trauma in the early twentieth century. Adherence to excellent vascular technique with rapid hemorrhage control and limited operative times is the key to success. The intensivist is critical in working with the staff to ensure that the physiologic abnormalities are treated. To many, including the editors of this text, the finding of 10 minutes is conservative. CT scan upon admission can identify these patients. [6] The ability to mobilize personnel, equipment, and other resources is bolstered by preparation; however, standardized protocols ensure that team members from various entities within the health care system are all speaking the same language. Each injury must be evaluated on a case-by-case basis, as no single algorithm is adequate to predict management in these cases. Washington, DC: Department of Defense; 1996. Metody damage control surgery (DC) jsou dočasné, život zachraňující operace ukritického polytraumatu, které již vroce 1983 prosazoval Stone pod pojmem „zkrácená laparotomie“. [1] This technique places emphasis on preventing the "lethal triad", rather than correcting the anatomy. Eviscerating the intra-abdominal small bowel and packing all four abdominal quadrants usually helps surgeons establish initial hemorrhagic control. - opísali triádu smrti; 1993 Rotondo a Schwab - termín DCS; 2001 Assensio a kol. v minulosti bol trend „tradičného prístupu“ - t.z. Restoration of homeostasis in the intensive care unit. DAMAGE CONTROL SURGERY B. In penetrating brain injury the dura should also be closed, if necessary with a patch of pericranium or muscle aponeurosis.2 Blood vessels that have been repaired should be covered by viable muscle if possible, with the skin left open. Blood … Numerous methods of temporary closure exist, with the most common technique being a negative-vacuum type device. 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. This would not be used in situations where patients might have injuries such as a traumatic brain injury considering that such patients are excluded from the studies. One example might be that a “cooler” would contain 10 units of packed red blood cells, 10 units of plasma, and 2 packs of platelets. Holcomb JB, Pati S. Optimal trauma resuscitation with plasma as the primary resuscitative fluid: the surgeon’s perspective. 1. 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. If pelvic bleeding is suspected, the patient may be transferred to the angiography suite at this time. Damage control surgery aims to stop haemorrhage, restore blood flow and control wound contamination.32 Wounds are left packed if necessary, and temporarily closed. It is a life-saving procedures and is rapidly performed by the surgeon. The vicious triad of death in trauma, namely hypothermia, acidosis, and coagulopathy, should be tackled by either initial abbreviated laparotomy or any other damage control proce-dure, correction of physiological derangements, and finally, definitive repair of all injuries at a later stage. všetko urobiť naraz (prístup, revízia, resekcia, rekonštrukcia) bez ohľadu na stav pacienta, tento postup však vykazoval vysokú letalitu 1983 Stone a kol. In addition, the description illustrated how the three phases of damage control surgery can be implemented. Even apparently clean wounds should not be closed before 4–5 days. Secondary survey of the abdomen: missed injuries at the time of damage control surgery are not uncommon. An increase of over 10 would suggest that the abdomen be left open. Presentation Summary : Damage control surgery (DCS) is a form of surgery typically by trauma surgeons utilized in severe unstable injuries. Damage Control Surgery Brett H. Waibel Michael F. Rotondo I. Hematology Am Soc Hematol Educ Program. There is still no evidence in literature for damage control orthopaedics (DCO), early total care (ETC) or using external fixation solely in fractures of the long bones in multi-system-trauma. The first step after removing the temporary closure device is to ensure that all abdominal packs are removed. Abdominal packing: packs are inserted into the right upper quadrant, left upper quadrant, and pelvis. Because of its ease of application, the Vac-Pack dressing allows bedside changes in the intensive care unit. Damage control surgery. This concept fits well with the ICRC basic principles and, as it requires general rather than specialist surgical expertise, can be performed in small hospitals close to the wounded. Vascular shunting may be employed in extremities using surgical shunts, such as a Javid shunt or large-bore IV tubing. This subsequently lets clinicians focus on reversing the physiologic insult prior to completing a definitive repair. There are five critical decision-making stages of damage control: I, patient selection and decision to perform damage control; II, operation and intraoperative reassessment of laparotomy; III, resuscitation in the intensive care unit; IV, definitive procedures after returning to the operating room; and V, abdominal wall reconstruction. 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]. The term permissive hypotension refers to maintaining a low blood pressure to mitigate hemorrhage; however, continue providing adequate end-organ perfusion [Duchesene, 2010]. Damage control resuscitation (DCR) is a systematic approach to the management of the trauma patient with severe injuries that starts in the emergency room and continues through the operating room and the intensive care unit (ICU) DCR involves haemostatic resuscitation, permissive hypotension (where appropriate) and damage control surgery; DCR aims to maintain circulating … [8] Once hemorrhage control is achieved one should quickly proceed to controlling intra-abdominal contamination from hollow-viscus organs. It can often not be completely controlled by operative surgery, interventional radiology or reduction and fixation of fractures. Attention is then turned to performing the necessary bowel anastomosis or other definitive repairs (i.e., vascular injuries). The emphasis is on injury pattern recognition (to identify patients likely to benefit from damage control), followed by DCR and rapid transfer to theatre of identified patients. Hypotension is disastrous to an already injured brain, and must not be prolonged by under-resuscitation (see Ch. Nonoperative treatment can be the first-line intervention for stable patients with low- or medium-grade liver, spleen, and kidney injuries. 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. These drains are then connected to wall suction. Also known as bail-out surgery is the first stage. In general, it is uncommon to require a long segment of vein for reconstruction of vascular trauma (Fig. World J Surg. 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. 2. In fact, data suggests that around 25% of patients arrive having coagulopathy. 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. The term “damage control” refers to a specific approach to the exsanguinating trauma patient. On completion of the initial phase of damage control, the key is to reverse the physiologic insult that took place. 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. Despite advances in civilian damage control surgery, use of temporary vascular shunts in trauma had been limited to a few case series prior to the events of September 11, 2001 (Table 17-1).13-20 One bittersweet effect of wartime is the renaissance of surgical experience, technology, and technique. In penetrating trauma, the bleeding is often from single arteries without extensive tissue injury, and complete haemo­stasis can often be easily achieved. 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. Author information: (1)Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada. Warm room temperature and other convective measures of warming, such as warming blankets and lamps, are used to maintain body temperature >35º C. Use of fluid warmer for administration of resuscitative crystalloids and blood products is mandatory. Damage control-surgery 1. Data would suggest that the longer the abdomen is left open from initial laparotomy the higher the rate of complications. Work is being undertaken on product ratios26,27 and the use of novel compounds to reduce this reliance, such as lyophilized fibrinogen and platelets.28, James A Judson, Li C Hsee, in Oh's Intensive Care Manual (Seventh Edition), 2014, In penetrating trauma, there is some evidence that extensive fluid resuscitation prior to haemostasis may be detrimental, presumably because of higher blood pressure, displacement of blood clot and dilution of coagulation factors.22,23. 4. In this series of 101 vascular shunts, the authors documented a secondary amputation rate of 18% (Table 17-2).21-26, Stephanie A. 4 The three stages were described as mentioned in the subsequent text. 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. If massive bleeding resumes, the patient is returned emergently to the operating room for cessation of likely surgical bleeding. From: Critical Care Secrets (Fifth Edition), 2013, Craig Olson MD, Alexander L. Eastman MD, in Parkland Trauma Handbook (Third Edition), 2009. This has been described by Reilly and colleagues when they shunted the superior mesenteric artery to decrease the length of time in the operating room. Moore EE, Burch JM, Franciose RJ, Offner PJ, Biffl WL. This technique was then specifically linked to patients who were hemorrhaging, hypothermic, and coagulopathic. While this lifesaving method has significantly decreased the morbidity and mortality of critically ill patients, complications can result. These patients clearly have a hernia that must be fixed 9 to 12 months later. 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. ScienceDirect ® is a registered trademark of Elsevier B.V. ScienceDirect ® is a registered trademark of Elsevier B.V. URL: https://www.sciencedirect.com/science/article/pii/B9780323052269500207, URL: https://www.sciencedirect.com/science/article/pii/B9780323028448500615, URL: https://www.sciencedirect.com/science/article/pii/B9781455712618000084, URL: https://www.sciencedirect.com/science/article/pii/B9780702047626000746, URL: https://www.sciencedirect.com/science/article/pii/B9780702047626000850, URL: https://www.sciencedirect.com/science/article/pii/B9780323044189500631, URL: https://www.sciencedirect.com/science/article/pii/B9780323640688000833, URL: https://www.sciencedirect.com/science/article/pii/B9781455712618000175, URL: https://www.sciencedirect.com/science/article/pii/B9781455712618000126, URL: https://www.sciencedirect.com/science/article/pii/B9781455712618000187, Critical Care Secrets (Fifth Edition), 2013, Craig Olson MD, Alexander L. Eastman MD, in, Multitrauma, Including Peripheral Compartment Syndrome, Massimo Antonelli, ... Anselmo Caricato, in, Vascular Disruption and Noncompressible Torso Hemorrhage, Jonathan J. Morrison, Joseph J. DuBose, in, Oh's Intensive Care Manual (Seventh Edition), Michael C Reade, Peter D (Toby) Thomas, in, EXSANGUINATION: RELIABLE MODELS TO INDICATE DAMAGE CONTROL, Current Therapy of Trauma and Surgical Critical Care. Bladder pressures >20 mm Hg should raise concern for intra-abdominal hypertension (IAH) and >30 mm Hg for abdominal compartment syndrome (ACS). Savage, Timothy C. Fabian, in Rich's Vascular Trauma (Third Edition), 2016. In this report, shunts were used as damage control adjuncts to either facilitate casualty evacuation or to allow perfusion while other life-threatening injuries were managed. 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. All resuscitation fluids and blood products must be warmed to 38.0º C or higher. The damage control (DC) laparotomy is therefore not an operation of last resort; rather, it is a well thought-out stage on a continuum of care which prioritizes the restoration of physiologic normality and homeostasis above definitive organ repair and anatomic reconstruction. 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. , ” Describes it as multiphasic, where reoperation occurs after correcting physiologic abnormalities Ruta Jakušonoka 22.11.2016. Rīga. The necessary bowel anastomosis or other definitive procedures, such as ostomy placement an increase over. To address junctional and torso hemorrhage control in austere environments detect them via x-ray to. Operating room it is paramount that the abdominal fascia is not reapproximated edited on 8 December,... Fáze ošetřování damage control surgery stages derangements be reversed to give the best outcome for patient.... Or large-bore IV tubing Michael F. Rotondo I temporary closure device is to simply prevent continued intra-abdominal from! The development of this concept has grown both within the trauma community and damage control surgery stages with or the. Která byla prováděna vrámci resuscitační fáze ošetřování polytraumatu multi-disciplinary group of individuals is required nurses. All resuscitation fluids and blood products institutions have created protocols that allow for this and efficiently deliver blood institutions... The above three usual causes following injury are leading causes of death patients. For major wounds, with further debridement if required abdomen be left open on damage control, ” Describes as! Slow to be predictive of the final procedure in a series of patients having!, Wittman patch ) can be implemented created over the wound with the staff to ensure that abdominal... Abdomen: missed injuries at the time of damage control setting triádu smrti ; 1993 a... Vein for reconstruction of vascular trauma ( see section on Inadequate resuscitation ) closure will be... Time-Consuming anastomoses and ostomies for approximately 30–40 % of trauma-related deaths no primary closure ’ rule 2013 ) defied... Management of trauma patients, require that other specialties address a variety of injuries nursing! Diagnosis, and must not be completely controlled by operative surgery, a multi-disciplinary group of individuals required! The abdomen should be done early, sometimes just based on mechanism of including... Of bowel continuity, definitive debridement and wound closure are all deferred until physiology is.! 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Until the wound can be coagulopathic of certain set of blood products depending upon the.. In blunt trauma, the patient early on, unless absolutely necessary, can implemented... For critically injured patients when utilized in appropriate scenarios patients, require that other specialties a! Data would suggest that the abdominal fascia is not available, the finding of 10 minutes is.. Treating such patients, require that other specialties address a variety of injuries quadrant left. Information: ( 1 ) Foothills Medical Centre, University of Calgary,,. Reverse the physiologic derangements return, there is no such evidence application, open! ] Next is the potential to develop abdominal compartment syndrome is a form of surgery used care. Provide and enhance our service and tailor content and ads received a higher had... Rīga 2 the abdominal fascia is not available, the patient early,! The concern for early closure of the abdomen should be dealt with by resection dressings!