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Damage Control Surgery - Concepts and Practice J R Army Med Corps 2000; 146: 176-182 J R Army Med Corps: first published as 10.1136/jramc-146-03-05 on 1 October 2000. Downloaded from REGULAR REVIEW Damage Control Surgery - Concepts and Practice DMG Bowley, P Barker, KD Boffard Introduction prospective series of 637 patients treated for The traditional surgical approaches to severe liver injury, three were considered for resuscitation and trauma have been based insertion of perihepatic packs and all three on tried and tested methods of managing survived (7). In 1978 AJ Walt summed up penetrating injury with exploration, control the growing confidence with packing when of bleeding and contamination and he said, “I have no wish to revivify the idea attempts to achieve definitive repair of of the pack as a desirable standard practice. damaged structures. The ‘damage control’ On the other hand, the judicious surgeon approach was born out of a need to meet who chooses this method should in no way the challenge of the changing scope and fear the whispered loss of his surgical severity of urban violence in America and manhood” (8). Calne, in 1979, reviewed 4 elsewhere over the last decade and a half. patients treated in this manner, all returned Increased use of semi-automatic weapons, to theatre for definitive surgery and all often with altered ammunition and fired survived (9). Following this trend, in 1981, with higher muzzle velocity, has led to Feliciano described a series where nine out increased numbers of patients presenting of ten patients survived when intra- with exsanguination and critical abdominal packing was used to control physiological instablity (1). Surgeons have hepatic haemorrhage (5). Stone went been forced to reconsider their approach to further, and in 1983, described a stepwise the critically injured patient and to revisit approach using intra-abdominal packing their preconceptions. It has become and rapid termination of laparotomy with necessary to stand back and look from a suggestions for temporising manoeuvres for new perspective - described as an ability “to other injured organs, such as the intestines think outside the box” (2). and urinary tract. A 65% survival rate in 17 patients was reported with this approach (10). In 1992, Burch reported 200 patients Maj DMG Bowley Historical perspective treated with abbreviated laparotomy and http://militaryhealth.bmj.com/ FRCS RAMC The concept of ‘damage control’ surgery Specialist Registrar in in the management of trauma victims is that planned re-operation with 33% survival General Surgery only the minimum is done to stop bleeding (11). The following year, Charles Schwab Dept of General and limit or contain contamination before in Philadelphia coined the phrase “damage Surgery the wound or cavity is packed and/or control” and detailed a standardized Derriford Hospital temporarily closed. The patient is then approach with a 58% survival rate (12). Plymouth PL6 8DH taken to Intensive Care and attempts are Damage control has now firmly entered the made to ‘normalise’ the patient surgical vocabulary and the underlying E-mail: concepts have found application not only in [email protected] physiologically before returning to the operating theatre for definitive surgery.This the abdomen, but also for injury to the chest The Revd Prof P Barker breaks the lethal cycle of hypothermia, and pelvis, for urological, vascular and on October 1, 2021 by guest. Protected copyright. MS FRCS FICS acidosis and coagulopathy. extremity injury and even in obstetric Surgeon Commander Despite this apparently novel approach, practice to treat spontaneous hepatic Royal Navy temporising manoeuvres in the treatment of rupture during childbirth (13). Defence Medical critically injured patients are not new. In Services Professor of 1908, Pringle introduced a technique to Physiological rationale for Clinical Surgery control bleeding from hepatic trauma by Royal Hospital Haslar damage control Gosport Hants using gauze pads secured by sutures (3). Trauma has been described as a ‘disease of PO12 2AA This approach was described in detail and bleeding’ (14). Recognition of acute blood subsequently modified by Halstead in 1913 loss after injury, and restoration of Prof KD Boffard FRCS (4). Packing for control of hepatic homeostasis is the cornerstone of the initial FRCS(Ed) FACS haemorrhage fell out of favour and by the care of the badly injured patient. Ongoing Professor of Trauma end of World War II the technique was haemorrhage leads to the onset of a cycle of Surgery almost universally condemned due to three inter-related variables, metabolic Johannesburg Hospital problems with re-bleeding on pack removal acidosis, profound hypothermia and a Trauma Unit and late sepsis (5). In 1955, Madding once Post net Suit 235 clinically obvious coagulopathy (figure 1). Private bag x2600 again used packs to control bleeding but Each of these factors reinforces the others Loughton emphasised that the packs should be and death of an exsanguinating patient is Johannesburg removed by the end of the operation (6). In due to the consequences of what Kashuk South Africa 1976, Lucas and Ledgerwood described a and Moore have described as “this bloody 177 Damage Control Surgery J R Army Med Corps: first published as 10.1136/jramc-146-03-05 on 1 October 2000. Downloaded from mortality was 100% if the temperature fell below 32°, even in mildly injured patients. Aggressive re-warming has been shown to be associated with significant reduction in mortality, blood loss, fluid requirement, organ failure and length of intensive care unit stay (21). The Damage Control Sequence a) Patient selection Most patients with penetrating abdominal injury require traditional management, with abbreviated laparotomy being necessary in only a few. During a 3 year period at the University Hospital in Cali, Columbia, 2437 laparotomies were performed for trauma. Of these, 117 (4.8%) required damage control (22). Damage control should be limited to those few patients who are critically unstable, with associated multi-visceral injury and exsanguination. It may be possible to identify, or ‘pre- Fig 1. Pathogenesis of the bloody vicious cycle after severe injury is multifactorial, but progressive core hypothermia select’ patients who are likely to need the and persistent metabolic acidosis are pivotal. Reprinted from damage control approach before theatre, AmJ Surg. 1996; 172(5): 405-10 Staged laparotomy for based on mechanism of injury, method of the hypothermia, acidosis and coagulopathy syndrome. presentation and initial physiological Moore EE. Copyright (1996) with permission from compromise. High-energy blunt trauma or Excerpta Media Inc. penetrating injury associated with abnormal vicious cycle” (15). vital signs should alert the physician to the The thermoneutral zone (28°) is defined possibility of severe or ongoing bleeding. as the ambient temperature at which the Arterial blood gases can be helpful on basal level of thermogenesis is sufficient to presentation, with a base excess > -6 offset ongoing heat loss, and sympathetic suggesting significant hypovolaemia. Blood tone is neutral (16). When ambient lactate >2.5mg/L, is also a useful marker, if temperature is below the thermoneutral readily available. zone and tissue oxygen consumption is The decision to abbreviate a laparotomy limited by shock, heat production cannot should ideally be made within the first few offset loss and hypothermia occurs despite minutes of the operation, if not decided on http://militaryhealth.bmj.com/ maximal sympathetic drive. Transfusion of before (23).The onset of diffuse bleeding in fluids, exposure of the patient in a cold a cold patient implies the physiological limit resuscitation room and surgical opening of of the patient has already been passed. body cavities compounds the problem. Carrillo demonstrated that a core Furthermore, decreased thermogenesis is temperature of 34°, a pH of <7.25 and often complicated by anaesthetic agents and coagulopathy are associated with high paralysing drugs that can decrease heat mortality (24). In a retrospective series of production by up to 33% (16). Core body 56 laparotomies for major trauma which temperature below 35° significantly affects were terminated abruptly, evidence of a the ability of the blood to clot (17) and cold- diffuse coagulopathy was present in 37 and on October 1, 2021 by guest. Protected copyright. mediated platelet dysfunction can result in not in 19. Of the 37 coagulopathic patients, coagulopathic bleeding despite an normal 16 died; whereas only 3 died out of 19 when count. Laboratory measurements for standard coagulopathy was absent (25). laboratory values are obtained in specimens warmed to 37°, hence clotting times may be b) Initial laparotomy normal in the face of a significant A full midline incision is made, after coagulopathy due to hypothermia (18). prepping the patient to anticipate the need Bernabei found hypothermia to be an for thoracotomy, sternotomy or vascular independent risk factor, predictive of access as necessary. Haemoperitoneum is increased blood loss during laparotomy for evacuated and the abdomen packed in four trauma (19). Jurkovich, measured the quadrants. Control of haemorrhage is lowest recorded core temperature in a achieved either by direct means using group of injured patients and stratified them sutures, ligatures, clips or electrocautery or according to Injury Severity Score, blood by indirect means with use of packs or and fluid requirements and presence or balloon tamponade for deep hepatic absence of shock. Patients who became wounds (26). Packing is the fastest and best hypothermic (<35°) had significantly higher way to control bleeding from a disrupted mortality than patients with similar injuries liver (22). Even retrohepatic caval injury who remained warm (20). In this study, may be managed by packing alone (27,28). DMG Bowley, K Boffard, P Barker 178 J R Army Med Corps: first published as 10.1136/jramc-146-03-05 on 1 October 2000. Downloaded from There is a definite ‘learning curve’ to the and laid on the adherent surface of a sheet use of packing in trauma surgery.
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