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. 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. Copyright © 2021 Elsevier B.V. or its licensors or contributors. Secondary survey of the abdomen: missed injuries at the time of damage control surgery are not uncommon. 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. [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. Initial resuscitation of trauma patients continues to evolve. [7] The U.S. military did not encourage this technique during World War II and the Vietnam War. Damage control-surgery 1. However, the ability to evaluate objectively the differences and then choose the one that fits your team is important. Restoration of gastrointestinal and vascular continuity if necessary, Performance of other definitive procedures, such as ostomy placement. It is important to not only pack areas of injury but also pack areas of surgical dissection. However, the ability to evaluate objectively the differences and then cho… In these scenarios, exposing and controlling the vascular injury with or without the use of a vascular shunt is accomplished first. Final abdominal fascial closure will likely be part of the final procedure in a damage-control scenario. DCS is improving overall survival rates and is gaining acceptance among surgeons. The resuscitation period lets any physiologic derangements be reversed to give the best outcome for patient care. In penetrating trauma, the bleeding is often from single arteries without extensive tissue injury, and complete haemostasis can often be easily achieved. 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. 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. 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. 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 process continues every 48 hours until the wound can be closed. This lets granulation occur over a few weeks, with the subsequent ability to place a split-thickness skin graft (STSG) on top for coverage. Washington, DC: Department of Defense; 1996. [18][19] Next is the development of an entero-atmospheric fistula, which ranges from 2 to 25%. There are various methods that can be used to pack the abdomen. In up to 40% of military extremity vascular injuries, the patient has a concomitant orthopedic fracture. The following goes through the different phases to illustrate, step by step, how one might approach this. 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. This is referred to by some as damage control ground zero (DC0). Damage control surgery can be divided into the following three phases: Initial laparotomy, Intensive Care Unit (ICU) resuscitation, and definitive reconstruction. Base deficit >8 mEq/L or worsening base deficit. 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. In general, it is uncommon to require a long segment of vein for reconstruction of vascular trauma (Fig. 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. [15] Patients who are arriving severely injured to trauma centers can be coagulopathic. Advanced modes of mechanical ventilation may be necessary for patients with packed thoraces. While the temptation to perform a definitive operation exists, surgeons should avoid this practice because of the deleterious effects on patients can result them succumbing to the physiologic effects of the injury, despite the anatomical correction. 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. Prior to being taken back to the operating room it is paramount that the resolution of acidosis, hypothermia, and coagulopathy has occurred. Savage, Timothy C. Fabian, in Rich's Vascular Trauma (Third Edition), 2016. The leading cause of death among trauma patients remains uncontrolled hemorrhage and accounts for approximately 30–40% of trauma-related deaths. 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]. This specifically relates to factors such as acidosis, coagulopathy, and hypothermia (lethal triad) that many of these critically ill patients develop. 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. Despite changes in prehospital care and patient transport, open surgical and interventional repair, damage control surgery, and ICU management, mortality from this triad of highly lethal venous injuries has changed little over the last 3 decades.7,11,30 In comparison to large series compiled in the 1980s and 1990s, mortality has actually worsened. Nevertheless, fluid resuscitation must not be used as an excuse for delaying haemostasis in blunt trauma. Daniel J. Scott, Todd E. Rasmussen, in Rich's Vascular Trauma (Third Edition), 2016. The concept 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. World J Surg. Bailout/damage control surgery following trauma has developed as a major advance in surgical practice in the last 20 years. 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. By continuing you agree to the use of cookies. Surgeons have used the concept of damage control surgery for years, and controlling hemorrhage with packing is over a century old. [2][3] Damage control surgery is meant to save lives. For re-exploration that involves re-opening, completely exploring, and irrigating the abdomen, where no other major procedures (for example, bowel anastomosis or resections) are perfor… Packing with radiopaque laparotomy pads allow for the benefit of being able to detect them via x-ray prior to definitive closure. 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. Lucas and Ledgerwood described the principle in a series of patients. Since this description the development of this concept has grown both within the trauma community and beyond. The concern for early closure of the abdomen with development of compartment syndrome is a real one. CT scan upon admission can identify these patients. [1] For trauma teams to systematically and efficiently deliver blood products institutions have created protocols that allow for this. [17] Subsequent studies were repeated by Feliciano and colleagues,[18] and they found that hepatic packing increased survival by 90%. 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. [5] Minimizing the length of time spent in this phase is essential. 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. If the greater saphenous vein is not available, the lesser saphenous, the cephalic, or the basilic veins should be considered. Nonetheless, one notable drawback of greater saphenous vein is the time and expertise required to harvest the conduit. A number of different techniques can be employed such as using staplers to come across the bowel, or primary suture closure in small perforations. This subsequently lets clinicians focus on reversing the physiologic insult prior to completing a definitive repair. ).24–26 9 to 12 months later an intensive care unit loss initiates the of... Of DCS is a life-saving procedures and is gaining acceptance among surgeons abdominal! Depending on how severe the initial phase of damage control process a that! 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