© 2004 Indian Journal of Surgery www.indianjsurg.com

Review Article

A logical approach to trauma –

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 victims can be improved by the principles of damage control surgery. The vicious cycle of trauma triad, namely, , and should be intercepted by the quick abbreviated laparotomy and subsequently physiological imbalance is corrected by secondary in the surgical intensive care unit. Definite repair can be taken later on. Abdominal 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 , care units. There was better understanding of body characterized as the . These were physiology supported by excellent equipment for hypothermia, coagulopathy and acidosis.3 intraoperative and postoperative monitoring of the patient along with adequate banks. Surgeons at DAMAGE CONTROL STRATEGY that time took up the challenge of more aggressively for complete repair of complex 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 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 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 in The second phase of damage control service begins in grossly lacerated 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. done for core rewarming of the body temperature (Table 3). Intra-cavitary bleeding of the liver from missile tracts can be controlled by balloon tamponade. Hollow As the resuscitation progresses, further inspections are viscous injuries are dealt with simple closures to made to identify occult injuries which are missed at prevent contamination. No attempt is made for the initial survey. The scalp, back, genitalias, and complex repair at this stage. Thorough irrigation of the extremities are the common sites for missed injuries. body cavities with warm isotonic solution should be done and quick temporary closure of the abdomen can Twenty-four to 48 hours are needed to correct the be achieved by the help of towel clips.11 In case of metabolic derangement. When the patient is massive bowel oedema and distension, direct closure adequately warm and the coagulation profile is of the abdomen may lead to abdominal compartment satisfactory, reverting back to the normal serum lactate syndrome. In such a situation silo bag closure12 or level is considered as the end point of secondary vacuum pack13 closure is useful to prevent rise in the resuscitation.14

Table 2: Damage control approach – Stage I DAMAGE CONTROL APPROACH: STAGE III (Operation Room) (PLANNED REOPERATION) Initial laparotomy/Abbreviated laparotomy/ Bail-out surgery Control of haemorrhage – Packing/Ligation/Clamping The timing of planned reoperation is critical. There is Balloon tamponade – by Sengstaken-Blakemore or usually a window period, 36 to 48 hours after the Foley catheter, useful in trauma, between the correction of metabolic disorder missile injury of the liver. and the onset of SIRS and MOF.15 Angio-embolisation – for expanding pelvic In this phase definitive procedures are undertaken. haematoma or liver injury Perihepatic packing or other packing is removed and not controlled by perihepatic packing small bleeding vessels are controlled. A thorough Control of contamination – Ligation/ Stapling/ Simple exploration is made for any hidden injuries. Restoration from perforated hollow viscous running suture of gastrointestinal continuity and vascular repair are Temporary abdominal closure – Towel clip/ silo bag (Bogota done. Provision for enteral feeding by jejunostomy or closure)/ vacuum pack gastrostomy as appropriate is made. A thorough

Table: 3 Damage control approach – Stage II – (Secondary resuscitation in SICU) Correction of metabolic disorder Core rewarming - Radiant heater, warm blanket Warm ventilatory circuits/ infusion Warm saline lavage through Intercostal Tube Arterio-venous rewarming using Level - I infuser Correction of coagulopathy - Infusion of FFP/ platelets/Recombinant activated human clotting factor VII (rFVIIa) Complete ventilatory support

Correction of acidosis - Correction of hypovolaemia Haematocrit > 21% HCO3/ vasopressor support Identification of occult injury - scalp, back, genitalia, extremity, PR/PV examination, fundoscopic examination

338 Indian Journal of Surgery 2004 Volume 66 Issue 6 (December) © 2003 Indian Journal of SurgeryDamage www.indianjsurg.com control surgery washout of the abdominal cavity with copious amount more than or equal to 12000 ml. of warm isotonic fluid is done before primary definite closure is attempted. The patient is then shifted to SICU The success of damage control surgery depends on a for further convalescence. disciplined approach, which includes proper decisions, rapid control, and rapid termination of the operation. Other than planned reoperation the patient may sometimes need early unplanned reoperation for COMPLICATIONS OF DAMAGE CONTROL ongoing haemorrhage, abdominal compartment SURGERY syndrome or peritonitis. Abdominal compartment syndrome PATIENT SELECTION FOR DAMAGE The abdominal compartment syndrome is a lethal CONTROL MEASURES (TABLE 4) complication of severe as well as abbreviated laparotomy. Unless recognized early this Only a small percentage of trauma patients require inflicts the other systems of the body leading to multi- damage control measures10 and early identification of organ failure. these cases produces optimal results. Certain conditions and complexes when assessed preoperatively can alert Causes of raised intra-abdominal pressure in abdominal the surgeon about the possible damage control trauma are listed in Table 5. When the abdominal 5 intervention. Peroperative assessment of some critical pressure rises to more than 25 cm of H2O, significant factors in unassuming cases also calls for damage cardiovascular, respiratory, renal and cerebral control application. Asensio et al16 recommended dysfunction occurs. certain intra-operative parameters as a guideline for instituting damage control. They suggested damage There is compression of the inferior vena cava and control intervention before reaching the upper limits diminished cardiac return of the blood due to of these parameters, which include pH less than or abdominal hypertension. Cardiac output is reduced equal to 7.2, serum bicarbonate level less than or equal while central venous pressure (CVP), pulmonary artery to 15 mEq/L, core temperature less than or equal to wedge pressure and systemic vascular resistance are 34o C, transfusion volume of packed RBCs more than increased. Respiratory parameters are altered because or equal to 4000 ml, total blood replacement more the diaphragmatic movement is restricted resulting in than or equal to 5000 ml, or total fluid replacement increased intrathoracic and peak airway pressure. As a result of this, intractable hypercapnia can occur due to Table: 4 Patient selection for damage control poor compliance of the lungs. Oliguria and anuria can surgery be precipitated by the compression of the renal vein Preoperative assessment High energy and renal parenchyma. The central nervous system is Multiple penetrating injury also affected as intracranial pressure is increased due Persistent haemodynamic to increased CVP preventing adequate venous drainage instability from the brain. Coagulopathy or hypothermia Complex presentation The abdominal compartment syndrome should be Multivisceral injury Multicavity and concomitant suspected in any patient having a period of profound visceral injury shock with multiple trauma. Clinical features are Multiregional injury abdominal distension, increased airway pressure, Peroperative assessment Severe acidosis, PH equal or < 7.2 difficulty in ventilation, and oliguria or anuria. The of the critical factors Serum bicarbonate level equal or <15 mEq/L Hypothermia Table 5: Causes of raised intra-abdominal equal or < 34o C Transfusion requirement pressure in abdominal trauma Packed RBCs equal or > 4000 Severe intra-abdominal bleeding Total blood replacement equal Massive transfusion and crystalloid infusions resulting in or > 5000 L intestinal oedema Total fluid replacement equal or Coagulopathy and non-surgical bleeding > 12000 L Intra-abdominal packing Coagulopathy – Non-surgical Closure of skin or fascia under tension bleeding clinically observed Severe infection causing bowel ileus or distension

Indian Journal of Surgery 2004 Volume 66 Issue 6 (December) 339 Ghosh S, et al.

diagnosis can be confirmed by measuring the intra- chance to survive in an otherwise hopeless situation. It abdominal pressure. This can be done by simple indirect is difficult to learn when to stop and can be learned method, either through a 3-way Foley catheter in the only from experience. The management of this complex bladder or Ryle’s tube in the stomach, attached to a problem requires a multidisciplinary team approach water column manometer. Normal intra-abdominal with patient counselling and communication with the

pressure is zero cm of H2O or less. Pressure over 35 family. 17 cm of H2O (Grade IV) is diagnostic. REFERENCES Management –Abdominal decompression is immediately indicated. Laparotomy and methods for 1. McGonial MD. Urban firearm deaths: A five year perspective. J temporary abdominal closure by towel clip, silo or Trauma 1993;35:532-40. 2. Feliciano DV, Burch JM, Spjut-Partinely VRN, Mattox KL, Jordan Jr zipper laparostomy should be considered. However, GL. Abdominal gunshot wounds. Ann Surg 1988;208:362-70. sudden decompression can produce some deleterious 3. Kashuk JL, Moore EE, Millikan JS, Moore JB. Major abdominal effects. As the compressed abdomino-pelvic veins are vascular trauma: A unified approach. J trauma 1982;22:672-9. 4. Rotondo MF, Schwab CW, McGonigal MD, Phillips GR 3rd, released, the effective cardiac preload is reduced and Fruchterman TM, Kauder DR, et al. “Damage Control” An approach a bolus of acid, potassium, and other by-products of for improved survival in exsanguinating penetrating abdominal anaerobic metabolism are washed into the systemic injury. J trauma 1993;35:375-83. 5. Rotondo MF, Zonies DH. Damage control sequence and underly- circulation. This may develop cardiac asystole, known ing logic. Surg Cl North Am 1997;77:761-77. as reperfusion syndrome.18,19 6. Slotman G, Jed F, Burchard K. Adverse effects of hypothermia in postoperative patients. Am J Surg 1985;149:495. 7. Frank SM, Beattie C, Christopherson R, Norris EJ, Peraler BA, GENERAL COMPLICATIONS Williams GM, et al. Unintentional hypothermia is associated with post operative myocardial ischaemia. Anaesthesiology These patients are basically very ill patients and they 1992;78:468-76. 8. Michenfelder JD, Uihlein A, Daw EF, Theye RA. Moderate hypo- tend to suffer from the same kind of complications as thermia in man: Haemodynamic and metabolic effects. Br J other critically ill surgical patients. Wound sepsis and Anaesth 1965;37:738-45. wound dehiscence are more common because of very 9. Gubler KD, Gentilello LM, Hassantash SA, Maier RV. The impact of high contamination. Risk of fistula formation is increased hypothermia on dilutional coagulopathy. J trauma 1994;36:847-55. 10. Johnson J, Gracias VH, Schwab CW, Reilly PM, Kauder DR, Shapiro with pancreatic injury, proximal bowel injury and bowel MB, et al. Evaluation in damage control for exsanguinating pen- exposed to air following dehiscence. ICU-related etrating abdominal injury. J Trauma 2001;51:261-71. infections like central line infection, suppurative 11. Feliciano DV, Moore EE, Mattox KL. Damage control and alterna- tive wound closures in abdominal trauma. In: Feliciano TDV, Moore thrombophlebitis, sinusitis, pneumonia are not EE, Mattox KL, editors. Trauma 3rd Ed. - Appleton & Lange; 1996. uncommon. Prophylactic heparin is indicated in high- p. 717-32. risk patients like , pelvic or lower 12. Mattox K. Introduction, background, and future projections of damage control surgery. Surg Clin North Am 1997;77:753-9. extremity fracture when coagulopathy and bleeding is 13. Baker DE, Kaufman HJ, Smith LA, Ciraulo Dl, Richart CL, PR. controlled. Special mattresses and proper nursing care Vacuum pack technique of temporary abdominal closure: A 7 year are needed to prevent skin complications. experience with 112 patients: J Trauma 2000;48:201-7. 14. Abramson D, Scalea TM, Hitchcock R, Trooskin SZ, Henry SM, Greenspan J. Lactic clearance and survival following injury. J trauma Psychological support and regular communication with 1993;35:584-9. the relatives of the patients are the other important 15. Brohi K. Damage control surgery. Trauma Org 2000;5:6. 16. Asensio JA, Petrone P, Roldan G, Kuncir E, Ramicone E, Chan Linda. aspects of this challenging surgical management. Has evolution in awareness of guidelines for institution of dam- age control improved outcome in the management of CONCLUSION posttraumatic open abdomen? Arch Surg 2004;139:209-14. 17. Burch JM, Moore EE, Moore Fa, Franciose R. The abdominal com- partment syndrome. Surg Cl North Am 1996;76:833-9. Damage control surgery represents an important 18. Shelly MP, Robinson AA, Hesford JW, ParkGR. Haemodynamic landmark in the historical spectrum of trauma effects following surgical release of intra-abdominal pressure. Br resuscitation. In trauma surgery, prolonging the initial J Anaesth 1987;59:800-5. 19. Morris JA Jr., Eddy VA, Blinman TA, Rutherford EJ, Sharp KW. operation can lead to disastrous results. Curtailing the Staged celiotomy for trauma. Issue in unpacking and reconstruc- operation does not mean abandoning but it gives a tion. Ann Surg 1993;217:576-86.

340 Indian Journal of Surgery 2004 Volume 66 Issue 6 (December)