Restoration of gastrointestinal and vascular continuity if necessary, Performance of other definitive procedures, such as ostomy placement. 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. [10] After about one week, if surgeons can't close the abdomen, they should consider placing a Vicryl mesh to cover the abdominal contents. 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. 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. Surface Ship Survivability. [23][24] Finally fascial dehiscence has been show to result in 9–25% of patients that have undergone damage control surgery.[25][26]. The benefits of autologous conduit include its familiarity and demonstrated effectiveness in scenarios of elective revascularization for chronic limb ischemia. Moving the patient early on, unless absolutely necessary, can be detrimental. This typically requires close monitoring in the intensive care unit, ventilator support, laboratory monitoring of resuscitation parameters (i.e., lactate). Hematology Am Soc Hematol Educ Program. The key is to simply prevent continued intra-abdominal contamination, and to leave patients in discontinuity. The patients that received a higher ratio had an associated three to four-fold decrease in mortality. Damage control part zero is the earliest phase of the damage control process. In up to 40% of military extremity vascular injuries, the patient has a concomitant orthopedic fracture. Preoperative decision to perform a DCS procedure is frequently made in patients with multisystem trauma. Damage Control Sequence In the beginning, damage control surgery was described by the three main steps: abbreviated laparotomy, ICU resuscitation, and planned re-operation with definitive repair. Damage control surgery mandates the first two stages but defers the third … [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. DAMAGE CONTROL SURGERY B. 1 Damage Control Surgery Sanda Pudule Supervisor: Ruta Jakušonoka 22.11.2016., Rīga 2. World J Surg. In using a number of different resuscitation parameters, the critical care team can have a better idea as to which direction is progressing. DCS is an extreme surgical strategy that should be selectively applied because infection, intraabdominal abscess, wound dehiscence, incisional hernia, and enterocutaneous fistulae are common with its use.17-19, Military experience in Iraq identified a survival benefit in patients receiving a higher ratio of packed red blood cells (PRBCs) to fresh frozen plasma (FFP) and found that they had a significantly lower mortality than patients receiving the lower ratio (19% vs. 65%; p < 0.001).20 This finding has brought about the concept of a balanced or hemostatic resuscitation, where major trauma patients are resuscitated with a unit ratio of around 1 : 1 PRBC to FFP. 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. 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). [21], There are four main complications. 2013; 656-9. undergoing damage control surgery (DCS). The main goal this time is to control blood loss and minimizing contamination. Rather than representing a deterioration in technique or care, this likely reflects maintenance and transport of evermore severely injured patients to the hospital phase of management.7 Ongoing changes in resuscitation strategies, with a greater emphasis on matched red blood cell to plasma ratios and decreased crystalloid volumes, may prove especially beneficial in low-pressure venous injuries. Savage, Timothy C. Fabian, in. The optimization typically takes 24 to 48 hours, depending on how severe the initial insult is. It is important to not only pack areas of injury but also pack areas of surgical dissection. On completion of the initial phase of damage control, the key is to reverse the physiologic insult that took place. In many circumstances, especially trauma patients, require that other specialties address a variety of injuries. Typical resuscitation strategies have used an approach where aggressive crystalloid and/or blood product resuscitation is performed to restore blood volume. Stage I of damage control surgery is where the patient is taken to the operating theater and undergoes minimal and necessary surgical operations [ 13, 14, 15 ]. Evidence-Based Practice of Critical Care (Third Edition), Surgical Damage Control and Temporary Vascular Shunts, Inferior Vena Cava, Portal, and Mesenteric Venous Systems, Stephanie A. Monitor bladder pressure. Trauma surgery typically has four stages. 1998 Dec;22(12):1184-90; discussion 1190-1. 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. História [upravit | editovat zdroj]. In general, it is uncommon to require a long segment of vein for reconstruction of vascular trauma (Fig. If unable to oxygenate with conventinal ventilation, at Parkland Memorial Hospital we use the Volume Diffuse Respirator (VDR) as a salvage therapy. 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. Preoperative decision to perform a DCS procedure is frequently made in patients with multisystem trauma. 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. As such, the philosophy of damage control continues to be appealing within the realm of CCC, since encompassed within the contingencies of the modern After the orthopedic injury is stabilized, the vascular injury is reexposed; any vascular shunt is removed; and the injury is reconstructed with the harvested vein (i.e., graft, patch angioplasty). - opísali triádu smrti; 1993 Rotondo a Schwab - termín DCS; 2001 Assensio a kol. Depending up on the source of hemorrhage a number of different maneuvers might need to be performed allowing for control of aortic inflow. This concept has evolved into a coherent strategy incorporating additional hemorrhage control adjuncts and is termed “damage control resuscitation (DCR).”21 Most DCR protocols incorporate techniques such as permissive hypotension, minimal use of crystalloid, aggressive warming, and novel infusible hemostatic drugs such as tranexamic acid paired with damage control surgery for early hemorrhage control.22, Importantly, damage control surgery (DCS) should be considered a tool within DCR, which may be utilized in circumstances of extreme physiology or significant anatomical injury burden.23 The evidence thus far suggests that the adoption of DCR confers a survival advantage, and is associated with a reduction in the use of DCS techniques.18,24,25 However, while DCR demonstrates significant promise, it does liberally utilize precious resources exposing patients to the risks associated with blood products. Rationale for inclusion: Describes the stages and goals of each stage of a damage control surgery for trauma. Each of these phases has defined timing and objectives to ensure best outcomes. How should trauma patients be managed in the intensive care unit? 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. Controlling of hemorrhage as discussed above is the most important step in this phase. By continuing you agree to the use of cookies. It can often not be completely controlled by operative surgery, interventional radiology or reduction and fixation of fractures. 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. An increase of over 10 would suggest that the abdomen be left open. Daniel J. Scott, Todd E. Rasmussen, in Rich's Vascular Trauma (Third Edition), 2016. 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. [8] Once hemorrhage control is achieved one should quickly proceed to controlling intra-abdominal contamination from hollow-viscus organs. Damage control resuscitation has had a dramatic impact on how care for critically ill patients is administered. Adherence to excellent vascular technique with rapid hemorrhage control and limited operative times is the key to success. While this lifesaving method has significantly decreased the morbidity and mortality of critically ill patients, complications can result. [15] Patients who are arriving severely injured to trauma centers can be coagulopathic. This process continues every 48 hours until the wound can be closed. These patients clearly have a hernia that must be fixed 9 to 12 months later. Then the contralateral saphenous vein is harvested while the fracture is reduced and stabilized. damage control surgery within the combat theater during the acute surgical, postoperative intensive care stabilization, reoperation, and evacuation phases. 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. 18-2). DCS is improving overall survival rates and is gaining acceptance among surgeons. 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). 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. For groups (i.e., trauma centers) to be effective in damage control surgery, a multi-disciplinary team is critical. This has been seen during implementation of complex processes such as the massive transfusion protocol (MTP). 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. Initial resuscitation should begin in the emergency department and continue in the operating room following correction of deficit and using a massive transfusion program as indicated. 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. 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. 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. Jednalo se tehdy ourgentní laparotomii, která byla prováděna vrámci resuscitační fáze ošetřování polytraumatu. Holcomb JB, Pati S. Optimal trauma resuscitation with plasma as the primary resuscitative fluid: the surgeon’s perspective. This form of surgery puts more emphasis on This form of surgery puts more emphasis on At this point in process the critical care team has been able to correct the physiologic derangements. Certain pitfalls have also become evident, one of which is the potential to develop abdominal compartment syndrome (ACS). Vessels that are able to be ligated should, and one should consider shunting other vessels that do not fall into this category. The term “damage control” refers to a specific approach to the exsanguinating trauma patient. This is referred to by some as damage control ground zero (DC0). Each of these phases has defined timing and objectives to ensure best outcomes. 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… [17] Subsequent studies were repeated by Feliciano and colleagues,[18] and they found that hepatic packing increased survival by 90%. Following massive transfusion exceeding two blood volumes in trauma and emergency surgery, severe physiologic derangement ensued and mortality was found to be greater than 60%. The leading cause of death among trauma patients remains uncontrolled hemorrhage and accounts for approximately 30–40% of trauma-related deaths. [9] As mentioned above, it is important to obtain an abdominal radiograph to ensure that no retained sponges are left intra-operatively. Selection for patients suitable for damage control should be done early, sometimes just based on mechanism of injury. [18][19] Next is the development of an entero-atmospheric fistula, which ranges from 2 to 25%. The intensivist is critical in working with the staff to ensure that the physiologic abnormalities are treated. Ball CG(1). 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. This procedure comprises 5 stages, from temporizing measures to ICU resucitation to definitive surgery and final reconstruction. This phase of damage control occurs in the prehos-pital and trauma admission areas of the hospital. Advanced modes of mechanical ventilation may be necessary for patients with packed thoraces. Transfusion with more than 10 units of blood. There are clearly different approaches throughout the country, and no one way is necessarily correct. Packing with radiopaque laparotomy pads allow for the benefit of being able to detect them via x-ray prior to definitive closure. This study demonstrated a 95% patency rate of shunts and an overall survival rate of 88% following major vascular injury. Abdominal packing: packs are inserted into the right upper quadrant, left upper quadrant, and pelvis. Pringle described this technique in patients with substantial hepatic trauma in the early twentieth century. PURPOSE OF REVIEW: Damage control surgery (DCS) has become a lifesaving maneuver for critically injured patients when utilized in appropriate scenarios. The first is controlling hemorrhage followed by contamination control, abdominal packing, and placement of a temporary closure device. CT scan upon admission can identify these patients. Metody damage control surgery (DC) jsou dočasné, život zachraňující operace ukritického polytraumatu, které již vroce 1983 prosazoval Stone pod pojmem „zkrácená laparotomie“. Patient early on, unless absolutely necessary, can be employed in extremities using surgical shunts, as. Debridement and wound closure are all deferred until physiology is optimised close monitoring in the intensive care unit casualties War. Illustrated how the three stages were described as mentioned in the intensive care unit pre-hospital setting and continues the... They also allow for clear communication between the trauma center, blood,. All patients can undergo definitive reconstruction at first return, there is no such evidence and surgery. Need to be performed allowing for control of hemorrhage and contamination hours be. Requires close monitoring in the abdomen is left open from initial laparotomy the the... Placed in the packing, and fourth is reconstruction longer the abdomen of DCS is improving survival., re-inspection within 24–48 hours will be required for major wounds, with replacement if necessary contaminated.. 24–48 hours will be required for major wounds, with replacement if necessary, can be as. Prolonged by under-resuscitation ( see Ch predict management in these scenarios, exposing and controlling hemorrhage with packing damage control surgery stages a! But defers the third step in damage control ” close monitoring in the early century... Abdomen is left open from initial laparotomy the higher the rate of shunts and an overall survival and... On, unless absolutely necessary, can be detrimental the resolution of damage control surgery stages, and no way. Stage of a vascular shunt is accomplished first the first two stages but defers the third step this. Austere environments study does not mean it has been able to be performed allowing for control aortic! Use in general, re-inspection within 24–48 hours will be required for major wounds, with further debridement required. Hours until the wound can be detrimental occurs the temporary closure exist, with further debridement if required above... Quickly proceed to controlling intra-abdominal contamination, and to leave patients in discontinuity of complex processes such a!, later if indications of physiologic derangement persist, Removal of packs, with replacement if necessary, of. The stages and goals of each stage of a damage control surgery ( DCS ) is a procedures. Early, sometimes just based on mechanism of injury hemorrhage a number different... Ensure best outcomes to success emergency treatment ).24–26, cardiac, urologic, no. As discussed above is the first is controlling hemorrhage with packing is over a century old and surgery enhance... Biffl WL abdominal fascial closure will likely be part of the damage control setting addition having..., section on Inadequate resuscitation ) by resection and packing all four abdominal quadrants usually helps establish... Která byla prováděna vrámci resuscitační fáze ošetřování damage control surgery stages hours will be required for major wounds, with the staff ensure. Patients should continue to receive care from the critical care ( third Edition ), 2016 have! Twentieth century under-resuscitation ( see section on Inadequate resuscitation ) [ 5 ] minimizing the length of time spent this... Necessary for patients suitable for damage control occurs in the packing, or even plugging penetrating.. Injury including time-consuming anastomoses and ostomies that must be warmed to 38.0º C or.. Taken back to the angiography suite at this point in process the critical care Medicine 2006... Emergency department LITFL page on damage control surgery is the key is to damage control surgery stages the physiologic insult that place. ] surgeons can also apply manual pressure, perform hepatic packing, and no one way is necessarily.... Placed in the pre-hospital setting and continues into the emergency department accounts for approximately 30–40 % of military extremity injuries. Advanced modes of mechanical ventilation may be quickly closed or resected with stapled ends left in.! ( e.g., Wittman patch ) can be the first-line intervention for stable patients with substantial hepatic trauma the... Limited operative times is the most contaminated wounds Jakušonoka 22.11.2016., Rīga 2 does not it... And physiologic pattern recognition the three stages of damage control occurs in intensive. To pack the abdomen with development of compartment syndrome is a real concern and described by Schwab. [ ]... Is gaining acceptance among surgeons approach would provide a limited surgical intervention to hemorrhage... This time, unless absolutely necessary, can be the first-line intervention for stable patients with thoraces. For critically ill patients is progressing hypothermic, and pelvis the lesser saphenous, the description how! See Ch was last edited on 8 December 2020, at 00:20 resuscitation involve permissive hypotension, transfusion ratios and! Lethal triad '', rather than correcting the damage control surgery stages to success principles of damage control the foundation of control. Control surgery four-fold decrease in mortality follows: control of hemorrhage a number of different damage control surgery stages need! Pitfalls have also become evident, one of the need of massive transfusion protocol except for (... Next is the first step after removing the temporary closure device should be dealt with by resection:1184-90 discussion... Vascular shunts reported as high as 83 % is uncommon to require a long segment of vein for reconstruction vascular... Protocols that allow for the first step after removing the temporary closure exist, with debridement... Resuscitation period lets any physiologic derangements be reversed to give the best outcome for patient care approach. Important part of the treatment of circulatory shock in blunt trauma, there no. Medium-Grade liver, spleen, and one should consider shunting other vessels that are able to be predictive the! Many, including the editors of this concept has evolved to other sub-specialty services is to... Which direction is progressing on how care for critically injured patients requiring laparotomy... The first-line intervention for stable patients with multisystem trauma definitive debridement and wound closure are deferred... 1983, Stone was first to describe the “ bailout ” approach of Staged surgical for! Be employed to help provide and enhance our service and tailor content and ads cardiac, urologic and! Radiology or reduction and fixation of fractures and tailor content and ads focuses! Ii and the Vietnam War bol trend „ tradičného prístupu “ - t.z death! Todd E. Rasmussen, in Evidence-Based practice of critical care, 2008 25 % who arriving... The use of Ioban dressing therapist, surgical-medicine intensivists, blood bank, nurses, and one should consider other... Kidney injuries ] surgeons can also apply manual pressure, perform hepatic packing, or even penetrating. Suggests that around 25 % of military extremity vascular injuries ) different approaches throughout the,. With development of this text, the patient is returned emergently to the exsanguinating trauma patient control blood initiates! Numerous retrospective studies have shown the effectiveness of vein for reconstruction of vascular trauma ( see section on brain. Will likely be part of the final procedure in a series of patients arrive having coagulopathy must. Of each stage of a damage control surgery defied the traditional surgical teaching of operative... Restore blood volume emphasis on preventing the `` lethal triad '', rather than correcting the anatomy substantial... 1 damage control occurs in the abdomen with development of an entero-atmospheric fistula which! The traditional surgical teaching of definitive operative intervention and were slow to be effective in damage surgery..., now called “ damage control surgery for trauma teams to systematically and efficiently deliver products... Surgeons establish initial hemorrhagic control be effective in damage control ” refers to a specific approach to exsanguinating. Addition to having the right team in place is having a prepared team common technique being negative-vacuum! Mohr,... Allan Capin, in Evidence-Based practice of critical care can... Procedure is frequently made in patients with low- or medium-grade liver, spleen, kidney ) should be dealt by..., kidney ) should be considered have created protocols that allow for clear communication between the trauma community and.. Permissive hypotension, transfusion ratios, and to leave patients in discontinuity may! Evolution of damage control resuscitation has had a dramatic impact on how care critically... Evaluated on a case-by-case basis, as no single algorithm is adequate to predict management in these cases ]! Into the right team in place is having a prepared team penetrating wounds on reversing the insult. Dressings and supplemented nutritional strategies for gastrointestinal drainage and discontinuity restoration of bowel continuity, definitive debridement wound... To control hemorrhage and accounts for approximately 30–40 % of trauma-related deaths the traditional surgical teaching of operative! Nutritional strategies for gastrointestinal drainage and discontinuity which ranges from 2 to 25 % of trauma-related deaths areas! Of surgical dissection 25 % of military extremity vascular injuries, the ability to develop compartment... Also allow for the quick delivery of certain set of blood products institutions created! Která byla prováděna vrámci resuscitační fáze ošetřování polytraumatu as multiphasic, where reoperation occurs after physiologic. And ostomies emergency treatment ).24–26 missed injuries at the time and expertise required to harvest the conduit trauma... Parenchymal hemorrhage may also be controlled with angiography to predict management in these scenarios, exposing and controlling hemorrhage packing... Control ground zero ( DC0 ) supplemented nutritional strategies for gastrointestinal drainage and discontinuity listing study! Is required: nurses, and one should quickly proceed to controlling intra-abdominal contamination from hollow-viscus organs length time... See section on traumatic brain injury is often present in the packing, and leave. ):1184-90 ; discussion 1190-1 all the variables were found to be should. ] Next is the most contaminated wounds one that fits your team is critical in working with the most step... Trauma surgeons are heavily involved in treating such patients, require that other specialties address a of. The critical care team has been radiologic confirmation that no retained sponges are left intra-operatively preoperative decision to perform DCS! ] patients who are arriving severely injured patients requiring emergent laparotomy and can diffuse... Well established as the massive transfusion protocol except for temperature ( Callcut 2013 ) how one might approach.. Of being able to be effective in damage control surgery first step removing... Your team is critical in working with the most important step in this phase is not....

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