Damage Control: Collective Review

Advances in prehospital care and trauma resuscitation have enabled the early survival of many injured patients who previously had a high chance of dying at the accident scene or en route to the hospital. The change in the spectrum of injury severity, characterized by high-energy blunt trauma with multiple-organ injury and fractures, and the emergence of semiautomatic handguns with multiple penetrating wounds, present new challenges to all surgeons. In conventional trauma care, definitive control and repair of all injuries may be accomplished in the immediate postinjury setting; however, the physiologic derangements of the massive shock state caused by the aforementioned injury patterns often lead to a fully repaired but dead patient. In response to these catastrophic challenges, the concept of “damage control” as a treatment merely to control but not definitively repair injuries has arisen. This term was originally coined by the United States Navy, in reference to “the capacity of a ship to absorb damage and maintain mission integrity.”1 In the patient with multiple injuries who is exsanguinating, this has been paraphrased to indicate the sum total of the maneuvers necessary to ensure patient survival above all else. 2 Definitive control of hemorrhage by pressure is not new to surgery. Pringle first enunciated the principles of compression and hepatic packing for control of portal venous hemorrhage in 1908. 3 This was modified by Halsted, who inserted rubber sheets between the liver and packs to protect hepatic parenchyma. 4 Military experience in World War II and Vietnam discouraged this practice. 5 As early as 1963, however, Shaftan et al. observed that to limit the mortality of liver injury, both faster and better resuscitation and better treatment of the wounds were necessary. 6 In 1979, Calne et al. described four cases in which massive exsanguinating hemorrhage from the liver was temporarily controlled with gauze packing, enabling safe transfer and definitive management at a more appropriate institution. 7 In 1983, Stone and associates popularized the technique of truncation of laparotomy, establishment of intra-abdominal pack tamponade, and then completion of definitive surgical repair later, once coagulation had returned to an acceptable level. This proved to be lifesaving in previously nonsalvageable situations. 8 Damage control, abbreviated laparotomy specifically to salvage trauma patients with exsanguination, was described at several institutions almost simultaneously in the early 1990s. 9–11 Rotondo et al. found a remarkable salvage rate of over 70% in a limited number of patients treated with damage control for abdominal vascular injury and massive shock, hypothermia, and acidosis. Since then, damage control has gained widespread use throughout North America, Israel, and South Africa. Recently, a review by Rotondo and Zonies identified 961 damage control patients in the literature, with 50% mortality and 40% morbidity overall. 12 Subsequent reports have expanded this list to over 1,000 patients (Table 1). Table 1: Cumulative Review of Damage ControlDamage control as currently practiced has three separate components. The first is abbreviated resuscitative surgery for rapid control of hemorrhage and contamination. This is obtained as quickly as possible in the operating room, but traditional repairs are deferred in favor of rapid measures that control hemorrhage, restore flow where needed, and control or contain contamination. Intra-abdominal packing and temporary abdominal closure complete this truncated first and critical step (Part I). The patient is then moved to the intensive care unit, where Part II consists of ongoing core rewarming, correction of coagulopathy, fluid resuscitation and optimization of hemodynamic status, as well as reexamination to diagnose all injuries. When normal physiology has been restored, reexploration is undertaken for definitive management of injuries and abdominal closure (Part III). 9,13 Increases in firearm violence present a new source of challenge to which damage control techniques are often applicable. In one study from the United States in an urban setting, firearm-related homicide increased by 123% over 5 years, and the number of victims who died at the scene rose from 5% to 34%. This was despite the designation of six trauma centers in that county, reflecting a shift toward high-velocity, high-caliber weaponry. 14 It has been apparent in our clinical practice for some time that inner city street weaponry and wounding patterns are changing, with multiple-shot injury patterns becoming much more common. These patients often present with multicavitary sites of exsanguination, and damage control techniques have assumed a prominent role in their initial management. This article reviews the principles of damage control as a series of linked surgical maneuvers, designed to address the physiologic abnormalities first, followed by a secondary resuscitative phase, and then the definitive surgical procedures themselves. Though damage control was traditionally described for massive abdominal trauma with vascular injury, recent applications in the chest and even to peripheral vascular injury have been reported. 15–17 GENERAL CONSIDERATIONS AND SECONDARY RESUSCITATION The goal of the damage control approach is to preserve the living patient. The triad of hypothermia, acidosis, and coagulopathy in the patient with multiple injuries is often lethal; Ferrara et al. reported 90% mortality in patients with these findings requiring massive transfusion. 18 Rewarming, replacement of coagulation factors, and fluid and blood resuscitation are critical to counter this state. 11 Damage control encompasses this algorithm, emphasizing rapid but definitive hemostasis, closing all hollow viscus injuries or performing only essential bowel resections, and delaying the more traditional or standard reconstruction until after the patient has been stabilized and all physiologic parameters have been corrected. Primary Operation and Hemorrhage Control The initial damage control laparotomy (Part I) includes five components: control of hemorrhage, exploration, control of contamination, definitive packing, and rapid abdominal closure. 19 An important distinction should be made between resuscitative and therapeutic packing. Resuscitative packing with manual compression of a bleeding site is often used as an initial short-term (minutes) measure to control or minimize blood loss while repairing other higher priority injuries or “catching up.”20 Therapeutic packing, in contrast, provides tamponade of bleeding when it is surgically unmanageable or a coagulopathy has developed. This is used to enable a longer period of resuscitation, to give the body time to correct the metabolic derangements mentioned above, 21 and to access other means of definitive vascular control such as therapeutic angiography. The decision to truncate the procedure should be made early when, in the judgment of the surgeon, definitive repair is either likely to exceed the patient’s physiologic reserve or is technically impossible. 22 The indications for damage control have recently been described in six general categories (Table 2). 23 Critical variables include the surgeon’s ability to control hemorrhage, the severity of the injuries, and the presence of other associated injuries. Packing as a therapeutic procedure should be implemented well before massive blood loss (10–15 units of packed red blood cells) has occurred. 24,25 Other variables that have been identified as significant include severe injury (Injury Severity Score >35), hypotension (shock in excess of 70 minutes), hypothermia (temperature <34°C), coagulopathy (prothrombin time >19 seconds or partial thromboplastin time >60 seconds), and acidosis (pH <7.2). 5,26,27 With these caveats, the need for packing as a planned therapeutic approach can often be anticipated preoperatively. Packing does not take the place of vessel ligation or clamping. Most vessels can be rapidly isolated, repaired, ligated, or shunted if necessary. Once definitive vascular control is obtained, packing of all raw or dissected surfaces is done. Occasionally, with injury to the liver, pelvis, or large muscle beds, packing must be done and prompt angiography performed to control these intraparenchymal or intramuscular vessels. Regardless of the bleeding source, expeditious vascular control is of paramount importance. Without it, exsanguination is ensured. Table 2: Indications for the Damage Control ApproachHypothermia, Acidosis, and Coagulopathy: The Lethal Triad Hypothermia Thermal homeostasis depends on a balance between the factors governing heat loss—conduction, convection, evaporation, and radiation—and the body’s ability to generate and maintain metabolic energy. Heat loss begins at the moment of traumatic insult, and is exacerbated by extenuating circumstances such as shock and low perfusion, prolonged exposure, immobility of the acutely injured patient, and extremes of age. In the absence of a preemptive treatment approach, this process continues in the emergency department, where the patient is unclothed and left fully exposed, with a resultant patient–room temperature gradient of 15°C. In this setting, measurable temperature loss occurs in up to 92% of patients. 28,29 Clinically significant hypothermia is considered present when the core temperature is less than 35°C, 30 and temperature less than 34°C has been linked with a need for early therapeutic packing. 27 Hypothermia has been reported in 21% of all severely injured patients, and up to 46% of trauma victims requiring laparotomy leave the operating room hypothermic. 29,31 Clinically, hypothermic patients have significantly greater fluid, transfusion, vasopressor and inotropic requirements, resulting in higher incidences of organ dysfunction, mortality, and markedly prolonged intensive care unit stay. 31–35 Hypothermia itself may not be the cause of these conditions, but it reflects the magnitude of the original injury and the associated shock state. Passive external rewarming techniques include patient shivering and simple covering of the patient to minimize convective heat loss. Active external rewarming techniques include fluid-circulating heating blankets, convective warm air blankets, and radiant warmers. Paradoxically, the initial response to these techniques may be adverse, as fluid shifts and changes in vascular tone decrease venous return, lower blood pressure, and diminish cardiac output. The return of cold, acidotic blood to the central circulation may initially lower core temperature, and has been associated with ventricular fibrillation during rewarming. 36,37 Active core rewarming techniques include warmed airway gases, heated peritoneal or pleural lavage, warmed intravenous fluid infusion, and extracorporeal rewarming. Cold (i.e., room temperature) intravenous fluid administration has been invoked as the fastest way of accelerating hypothermia. 28 Countercurrent heat exchange mechanisms have enabled the rapid infusion of warmed banked blood products. 38 Extracorporeal rewarming techniques may be limited by the need for anticoagulation. Continuous arteriovenous rewarming, however, can be accomplished with a heparin-bonded circuit without a pump that may eliminate this limitation. This process is driven by the patient’s blood pressure; hence, its effectiveness is limited by hypotension. This technique can accomplish rewarming at a rate of 4° to 5°C per hour, which is far more efficient than the 1° to 2°C possible with other methods. Because warmed blood is sent directly to core organs, continuous arteriovenous rewarming rapidly increases core temperature by nonshivering thermogenesis, which may increase metabolic effectiveness. 36 Acidosis Acidosis associated with hypovolemic shock contributes to coagulopathic bleeding, which worsens the shock state. Correction requires not only control of hemorrhage but also optimization of oxygen delivery, blood and of cardiac output. a of resuscitative have been that conventional and venous oxygen and of coagulation factors and by fluid resuscitation, total and hypothermia, the severity of injury, shock, and metabolic acidosis may all to the of normal The clinical of coagulopathy is not by that other than the of factors and the number and of may be in the of Hypothermia in the patient to of and coagulation of the of these is by of and partial thromboplastin in hypothermic conditions, even where coagulation factors are to be is performed at than at the patient’s core temperature, and may the of in hypothermia to prolonged bleeding from a in in by temperature may also the and of despite the replacement of is often between and bleeding in patients who have massive transfusion, and the presence of hemorrhage in this is an for even with a in hypothermic has been to the of in the and of may also lead to is a simple that can coagulation abnormalities and give and that is not from coagulation the of with the coagulation from initial and to It is for use in the operating room, the of coagulopathy, and may be an early of the need for in patients with blunt of the damage control approach to coagulopathic bleeding have been an initial by et al. in in mortality with et al. have reported high survival damage control Subsequent reports have described both in a of trauma patients (i.e., and in general surgery patients. and the Increases in intra-abdominal pressure may circulation and organ perfusion, the and This can from abdominal trauma by or the use of abdominal return is by compression and of and lower In increased abdominal pressure, associated and a increase in all to diminish cardiac output. blood flow to the liver, and may all be and to the of may also from compression of the can vascular and this from increased abdominal pressure with resultant in and worsens Paradoxically, in this may with of the and of this is the of this but is well described in the surgical 70 packing as a damage control procedure can be a cause of significant abdominal with compression of the to In this setting, a patient should be returned to the operating room for of if of some of the laparotomy to decrease intra-abdominal pressure and to in perfusion, cardiac and In the absence of this packs should be left in place until the patient’s hemodynamic has acidosis has and coagulopathy has been corrected. In this should be accomplished to of the initial packing. may be appropriate if was initially as this may the of a for injury should be is and abdominal closure should be performed if has to this without CONSIDERATIONS The of for rapid abdominal in the trauma patient is made in one from process to In the presence of severe the initially to above the may be In our experience with patients with a access to the can be gained a approach, to and of and bowel from the of the The initial maneuvers on the should be rapid but and are quickly of the abdominal is performed to enable multiple laparotomy packing. This initial packing of the sites of bleeding, from vascular in penetrating injury, or liver in blunt bleeding is less common. this a large abdominal is to abdominal and to all on the surgical bleeding controlled with the packing or during initial exploration, an injury was found and controlled with or this is an time to the to with and source of bleeding has been then a vascular injury is a likely source, and should be by more The bowel is and the are to the and their or the surgical This is important in penetrating pack from the sites of injury, and 19 Control of hemorrhage is the and is accomplished by repair or ligation of vessels. Critical such as the or can be shunted for temporary of can be simple or vascular between tamponade of vascular and viscus injuries has been but in our experience is less applicable. may be necessary for completion of control and temporary for this is high abdominal or or tamponade as a temporary measure to increase blood viscus injury must be controlled as to limit and may be accomplished with or without Occasionally, the injured bowel with or is to contain temporary control of hemorrhage and is obtained, the decision to with definitive repair must be made in with the In the of hypothermia, acidosis, prolonged shock, or coagulopathy, the procedure should be truncated and the patient to the intensive care unit for The presence and of injuries must be when the patient’s physiologic the more injured patient with more severe requires less to be done at this initial are the for damage control packing, and should be to three pressure bleeding, pressure should and should be have as have described the use of or as an between and packing to pack at but have not found these to be necessary. closure of the packed is accomplished by rapid closure the the of abdominal and the and The massive associated with fluid resuscitation and in these patients may even closure impossible. of a or intravenous fluid to has been described as a temporary in this have described to the to preserve the for closure use only the is to or use the for temporary closure. use a modified approach by an surgical over the of the abdominal with its the are above the and the and at the of the An is over the and and to the of the and while the abdominal are toward the The of to the abdominal fluid to the and a to the the has been described as a with the damage control approach, have had such in our this The of are definitive organ repair and complete closure. The should be undertaken when the patient is with correction of hypothermia, acidosis, and may be necessary if is of ongoing hemorrhage than units of packed red blood in the early acidosis, or abdominal massive may limit abdominal closure at but closure has been described in over of of is essential at and access should be the safe use of in an has been this is not our have or in the patient be of our experience that of the abdominal may at closure or of is limited to cases in which is other for of to initially with total and reserve until a can be in the patient. of a damage control may be appropriate for to to for of fluid and at closure. at this the be but the a large is with planned repair to 12 and be a abdominal reconstruction is with the of an closure. to 3 is for of a 6 to 12 this from the and closure can be requiring muscle the physiologic of the patient who requires the damage control approach, it is not that the rate of and mortality is includes intra-abdominal and abdominal organ is described in to of patients, significantly to the mortality rate of to In patients laparotomy for hepatic injury, of have been to to control liver bleeding include ligation of bleeding partial and hepatic tamponade and have also been packing or tamponade is an procedure to control The need for this approach has been reported in to 5% of liver injuries. be the packs must pressure and that are bleeding are not to control by The is injured in abdominal trauma and may present as a source of The patient in with injury requires immediate and at are and 19 Occasionally, the temporary packing to tamponade of vessels until coagulopathy is at the packs are and are at the surgeon’s and injuries to the and are often associated with vascular injury in the patient in mortality is to The should be the and of injury The should then be and Definitive repair is undertaken at and may include or more injury in the exsanguinating patient is with by rapid if a normal is in the of other severe injuries should be packed than to more bleeding and An however, ongoing hemorrhage from an and for In some for hemorrhage or may be more appropriate and than injuries are to reconstruction in the patient both bleeding is and temporary control of can be with can be injury in the patient can also be temporarily with a or Definitive repair can be accomplished at and are to the management of the severely injured patient with can restore of the in fractures, and venous bleeding is with by When laparotomy the of the of is to pack the with gauze to tamponade, the laparotomy, and directly to angiography for to control In our these cases are and closure has been necessary to limit the of and with and temporary at sites more conventional to in the patient in in the can be accomplished with temporary if injury is ligation should be considered as an and may be should be performed in the of In the time and blood should be the way to temporary closure and after physiologic Packing the when severely injured has physiologic and is limited to the and The goal of abbreviated is to bleeding and restore a physiologic state. of the can often rapidly and control of air may be an way to control hemorrhage in penetrating The the is between or with a vessel and control of air This the need for injury can be treated with airway control at the site of injuries, may be but can be to with with an can be repairs are not in the patient in and rapid of the or is injury is treated by and injury to control hemorrhage and maintain flow to repair and are rapid such as and at are time to use in the cold, exsanguinating patient. vascular control tamponade the site has been injury in the is for the patient in Most and can be to the patient’s (Table of the or or external however, often significant damage or This should be for the of situations. must be to lower and laparotomy to An to ligation may be the rapid of temporary or venous and is for time and blood performing reconstruction in the patient in must ligation to The damage control approach can be in operating room by general surgeons. the first of laparotomy or with control of bleeding and contamination, packing, and closure is for where experience with these injuries may be or the necessary for resuscitation may be Once Part is the patient can be to a trauma or with and in the patient management and definitive repair of the injuries. Damage control is of as a lifesaving in patients with exsanguinating trauma and intra-abdominal injuries. The technique can be in a of injury and is appropriate in patients acidosis, hypothermia, and coagulopathy from The resuscitation is at normal physiology and oxygen coagulopathy, hypothermia, and acidosis. of abdominal must be to The and pack is the time to definitive repair and and to place closure with or without must be done with on the and the of the from several up to of patients this approach, the of intra-abdominal and organ are study is to more better for this is also to the of to of resuscitation, better of temporary and to limit intra-abdominal and or blunt organ and The use of procedures and the of the damage control approach of surgical for injuries