© 2004 Indian Journal of Surgery www.indianjsurg.com Review Article A logical approach to trauma – Damage control surgery Shibajyoti Ghosh, Gargi Banerjee, Susma Banerjee, D. K. Chakrabarti Department of Surgery, R. G. Kar Medical college, West Bengal, India. ABSTRACT Trauma is the major cause of death worldwide. Survival of the major trauma victims can be improved by the principles of damage control surgery. The vicious cycle of trauma triad, namely, hypothermia, coagulopathy and acidosis should be intercepted by the quick abbreviated laparotomy and subsequently physiological imbalance is corrected by secondary resuscitation in the surgical intensive care unit. Definite repair can be taken later on. Abdominal compartment syndrome is the most formidable complication. Multidisciplinary team approach is needed to alleviate the physical and psychological trauma of the patient. KEY WORDS Damage control surgery, trauma triad, hypothermia, coagulopathy, acidosis, abdominal compartment syndrome. How to cite this article: Ghosh S, Banerjee G, Banerjee S, Chakrabarti DK. A logical approach to trauma – Damage control surgery. Indian J Surg 2004;66:336-40. Damage control surgery following trauma is one of the Organ Failure) were recognized and ultimately, the major advances in surgical practice in the last 20 years. majority of these patients died early in the The principles of damage control surgery were slow to postoperative period. Trauma surgeons began to be accepted worldwide because it defied the traditional introspect and tried to find out an alternative approach surgical teaching that, the first chance of any surgical of this hugely expensive and frustrating exercise. Thus intervention is the best chance for any definitive repair the concept of damage control surgery emerged almost or reconstruction, with good result. simultaneously all over the world towards the end of 1980.1,2 HISTORICAL PERSPECTIVE OF DAMAGE CONTROL SURGERY It was found that the cause of death in these trauma victims was not due to failure to complete the initial In the seventh and eighth decades of the last century, operation. The patients died because of the metabolic huge developments in science and technology were derangement or physiological alteration in the body also reflected in the operation theatre and intensive following severe exsanguinating polytrauma, care units. There was better understanding of body characterized as the trauma triad of death. These were physiology supported by excellent equipment for hypothermia, coagulopathy and acidosis.3 intraoperative and postoperative monitoring of the patient along with adequate blood banks. Surgeons at DAMAGE CONTROL STRATEGY that time took up the challenge of trauma surgery more aggressively for complete repair of complex injuries at The conventional sequence of the management of the first chance. The patients could survive the initial trauma surgery was to bring the patient to the operating onslaught but soon they succumbed to a new kind of room after initial resuscitation and then to operate for clinical situation. Conditions like shock lung syndrome complete repair of the injuries. Even patients with or ARDS (Adult Respiratory Distress Syndrome), SIRS multiple complex injuries were operated more (Systemic Inflammatory Response Syndrome), MODS aggressively over a prolonged period of time for (Multi Organ Dysfunction Syndrome), MOF (Multiple definitive primary repair. Subsequently, these patients Address for correspondence: Shibajyoti Ghosh, 50/1B, Harish Mukherjee Road, Kolkata - 700 025, India. E-mail: [email protected] Paper Received: June 2004. Paper Accepted: October 2004. Source of Support: Nil. 336 Indian Journal of Surgery 2004 Volume 66 Issue 6 (December) © 2003 Indian Journal of SurgeryDamage www.indianjsurg.com control surgery were sent to the intensive care unit where a good Table 1: Preventable causes of hypothermia number of the patients succumbed due to metabolic derangement of the body. The principles of damage Conductive heat loss control surgery replaced this sequence.4 At the first Inadequate protection or skin cover of the patient Patient lying in blood-soaked clothes and sheets in the phase of damage control strategy, only abbreviated emergency room or operation theatre laparotomy was done for lifesaving measures, then the Cold ambient temperature of the emergency room or patient was sent to the surgical intensive care unit operation room (SICU) for the correction of the metabolic disorder. Unwarmed infusion of crystalloid and blood Following satisfactory correction the patient was once Inhalation of unwarmed gas from the anaesthesia machine again taken to the operation room for definitive repair Exposed visceral and serosal surfaces during operation Irrigation of the wound or body cavity with cold fluid and sent back to SICU for further convalescence. thromboxane and prostacycline is affected in the TRAUMA TRIAD hypothermic state, resulting in platelet dysfunction. Severe injury and certain injury complexes like head The policy of damage control surgery was developed injury had shown to increase fibrinolysis. Thus, on the realization that most of the severely coagulopathy occurs due to hypothermia, platelet exsanguinating and polytrauma patients died from a dysfunction at low temperature, activation of the triad of coagulopathy, hypothermia and metabolic fibrinolytic system and haemodilution following acidosis. Once metabolic failure has become massive resuscitation. Hypothermia and haemodilution established it is extremely difficult to control have an additive effect on coagulopathy than either haemorrhage and correct the physiological factor alone.9 derangements. Different laboratory parameters of the coagulation Hypothermia - It is the inevitable sequence of severe profile, like prothrombine time, partial prothrombine exsanguinating injury and subsequent massive time, fibrinogen level, and lactic acid level, are not very resuscitative effort.5 Severe haemorrhage causing much predictive of the onset of a severe coagulopathic hypovolaemia leads to tissue hypoperfusion in the state in a cold, exsanguinating patient. In the body. This means diminished oxygen delivery at the intraoperative period, the clinical judgment of the senior cellular level and reduced heat generation. Clinically, surgeon to identify coagulopathy should be considered hypothermia is important if the body temperature for damage control measures.4,10 drops down to less than 97o F or (36o C) persistently for more than 4 hours.6 Hypothermia can lead to cardiac Acidosis – Anaerobic cellular metabolism starts when arrhythmias, decreased cardiac output, increased the shock stage or hypoperfusion is prolonged, systemic vascular resistance, left shift of oxygen– producing lactic acidosis. Acidosis is further increased haemoglobin dissociation curve, and can induce by massive transfusion, use of vasopressor drugs, aortic coagulopathy by inhibition of clotting cascade cross-clamping, and impaired myocardial performance. reactions.7,8 The immunological surveillance system is Consequently, the normal clotting mechanism is altered also impaired at a low temperature and this could play in the acid medium of the body. a crucial role in the survival of the patient. It is clearly evident that a complex relationship exists The surgeon should be aware of these consequences between these three factors and the presence of one and should take every measure to prevent further factor accentuates the other factor leading to exaggeration of hypothermia, which is easily progressive metabolic failure and death. preventable. Hypothermia is aggravated by heat loss either by conduction or convection due to To break this vicious triad of death, a systemic three- environmental factors and common practices followed phase approach was designed as a damage control in the emergency room or operation theatre (Table 1). approach. Coagulopathy – Every aspect of the normal clotting DAMAGE CONTROL APPROACH: STAGE I mechanism is affected in a cold acidotic exsanguinating patient. At a low temperature all the clotting cascade Primary resuscitation should start from the field and be reactions are inhibited producing decreased amount continued to the operation room. The first stage consists of clotting factors. Also, the balance between of initial laparotomy which is also known as abbreviated Indian Journal of Surgery 2004 Volume 66 Issue 6 (December) 337 Ghosh S, et al. laparotomy or bail-out surgery. Lifesaving procedures intra-abdominal pressure. (Table 2) are performed very rapidly and the operation is abbreviated by temporarily closing the abdomen. DAMAGE CONTROL APPROACH: STAGE II Control of haemorrhage is the top priority by quickly (SICU) clamping and ligating the major vessels. Perihepatic packing is most important for controlling bleeding in The second phase of damage control service begins in grossly lacerated liver injury or if the bleeding cannot the SICU where the resuscitation team tries hard to be controlled by the conventional methods. Optimum correct the metabolic disorder. Rewarming the patient compression should be done from both sides, superior is a high priority as coagulopathy and acidosis can only and inferior surface of the liver, to achieve haemostasis. be corrected and maintained when the body The drawback of this method is that underpacking may temperature returns to normal. Simple measures as fail to stop bleeding whereas overpacking may increase well as complex invasive procedures may need to be intra-abdominal pressure.