Damage control surgery

DAMAGE CONTROL SURGERY

Etymology• The term damage control was coined by US

navy during WWII.• Basic skill and procedure that can maintain

water tight integrity and offensiveness of war ships.

• Similar sinking ship is a traumatized patient.

Definition

• Damage control surgery (DCS) is a form of surgery typically by trauma surgeons utilized in severe unstable injuries.

• This form of surgery puts more emphasis on preventing the triad of death, rather than correcting the anatomy .

Trauma triad of death

Massive hemorrhage lead to :1. Hypothermia2. Metabolic acidosis3. Coagulopathy

Hypothermia

1. Heat loss by evaporation and conduction2. Inability to generate heat

Central cause of all derangements.

Metabolic acidosis

1. Massive transfusion2. Vasopressors3. Diminished cardiac function

Coagulopathy

1. Consumption dilution2. Hypothermia 3. Acidosis

Principles of damage control Surgery

• Stone insisted for rapid closure of abdomen for preventing hemorrhage.

• Now it is established that opening of abdomen for a long leads to loss of heat leading to hypothermia.

• Concomitant thoracic opening aggravates it.• Try all possible methods to break the vicious

cycle of lethal triad and restore physiology.

Steps is damage control surgery

Bleeding raw surfaces, like that of the liver, are packed with laparotomy pads.

Small enteric injuries are closed with staplesLarge ones are stapled on both sides with the

GIA stapling device and the damaged segment removed.

Injuries of the pancreas and kidneys are not treated if they are not bleeding

Clamps may be left on unrepaired vascular injuries, or the vessels are ligated.

Vessels which cannot be ligated without loss of life or limb can be treated with temporary indwelling shunts.

No drains are placed, and the abdomen is closed with sharp towel clips placed two centimetres apart which include only the skin.

Towel clips are used because they do not cause bleeding as needles do and they can be applied very rapidly, usually in 60–90 seconds.

The closure of just the skin allows for the abdominal or thoracic cavities to accommodate a greater volume without increased pressure.

The clips are covered with a towel, and a plastic adhesive sheet is placed over the towel to prevent excessive fluid from draining onto the patient's bedding.

Cold wet drapes are removed, and the patient is covered from head to toe with layers of warm blankets.

Definitive surgery

• Patient is taken for definitive surgery within 24 hours.

• If surgeon believes the metabolic derangements will improve within 2 hours patient can be kept in OT.

• If metabolic corrections will take a long time patient can be shifted to SICU .

Indications for definitive surgery

1. Core temprature 36°F or above2. Correction of acid base balance3. Normalization of coagulation profile.

Advantages

A. A small study on penetrating abdominal injuries showed a survival benefit over historical controls(90% v 58%; P=0.02).

B. Mortality in Iraq war was 10% compared with 24% in Gulf war.

Disadvantages

1. Sepsis and multi organ failure2. Pneumonia 3. Intra abdominal abscess4. Enteric fistula5. Compartment syndrome

Damage control neurosurgery

1. Arrest intracranial hemorrhage.2. Evacuate the hematoma.3. Primary closure of dura to prevent infection.4. Craniectomy to prevent compartment

syndrome.

Damage control orthopedics

• Control all hemorrhages primarily.• Avoid early manipulations of long bone

fracture.• Prevents fat embolism.• Two hit theory.

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