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Damage control surgery

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Damage control surgery is a relatively recent approach to the surgical component of trauma medicine, which focuses on doing "just enough" surgery to stabilize the patient before the lethal triad of trauma induced coagulopathy, hypothermia, and metabolic acidosis. The components of the lethal triad are metabolic rather than trauma (physical) that require definitive repair. It has been defined as "the rapid initial control of hemorrhage and contamination, temporary closure, resuscitation to normal physiology in the intensive care unit, and subsequent re-exploration and definitive repair."[1] As of 2010, while DCS is increasingly the practice among trauma surgeons, a Cochrane Collaboration review did not find enough evidence that it was definitively superior to conventional abdominal surgery, but also observed they found no randomized controlled trials for definitive comparison. [2]

"The modern operation is safe for the patient. The modern surgeon must make the patient safe for the modern operation" - Lord Moynihan

Its basic premise is that patients with multisystem trauma can only be submitted to enough surgery, at one time, for "control of hemorrhage, prevention of contamination and protection from further injury," without making the metabolic disorders worse. Trauma surgeons now routinely split what had been one lengthy procedure in many, then turning to surgical critical care to prepare for the next procedure. Damage control surgery first was widely used when 9mm gunshot wounds became common in civilian practice, inflicting damage that had previously been associated with battlefield weapons. The surgical approach then moved to Iraq and Afghanistan, and a new generation then came back for civilian use.[3]

Organizing for DCS

Not all DCS is preplanned and strategic; it may be a tactical decision. A surgeon may recognize the need for it before making the first incision, early in the operation, or when warning signs of nearing the lethal triad become apparent:[4]

  • Edema of the bowel mucosa
  • Midgut distension
  • Dusky serosal surfaces
  • Tissues cold to the touch
  • Non-compliant swollen abdominal wall
  • Diffuse oozing from surgical incisions

Supporting normal coagulation

Some of the techniques for avoiding coagulopathy include minimizing fluid infusion with crystalloid, permissive hypotension, damage control surgery, and transfusion with coagulation factors as well as packed red blood cells.[5]47% of standard massive transfusions in trauma produce potentially life threatening (hypo)coagulopathy (PT/PTT >2X) with massive transfusion.[6]

References

  1. Dave Ed. Lounsbury, ed. (2004), Chapter 12, Damage Control Surgery, Emergency war surgery' (3rd U.S. revision ed.), U.S. Department of Defense, p. 12-1
  2. Cirocchi R, Abraha I, Montedori A, Farinella E, Bonacini I, Tagliabue L, Sciannameo F. D (2010), "Damage control surgery for abdominal trauma", Cochrane Database of Systematic Reviews, DOI:10.1002/14651858.CD007438.pub2
  3. Janet Brooks (26 September 2006), ""Damage control" surgery techniques used on soldiers", CMAJ 175 (7), DOI:10.1503/cmaj.061095.
  4. Asher Hirshberg and Kenneth Mattox (2005), Top Knife: the Art & Craft of Trauma Surgery, TFM Publishing, ISBN 1093378222, p. 14
  5. Sandy Zalstein (6 May 2008), "Massive Transfusion Protocols that support Damage Control Surgery: A new dimension in critical care haematology", ARCBS Transfusion Update 2008, Australian Red Cross Blood Service
  6. Cosgriff, Moore, Sauaia et al. "Predicting Lifeet Life-Threatening Coagulopathy in the Massively Transfused Trauma Patient: Hypothermia and Acidoses Revisited." J Trauma 1997, cited by Zalstein