DCS is improving overall survival rates and is gaining acceptance among surgeons. There are clearly different approaches throughout the country, and no one way is necessarily correct. However, the ability to evaluate objectively the differences and then cho… Bowel injuries may be quickly closed or resected with stapled ends left in discontinuity. Keen and colleagues reported no graft infections in their population and attributed this success to liberal use of rotational muscle flaps and routing the autologous grafts in an extraanatomic manner out of any contaminated sites.49. If possible, maintain tidal volumes at 6 mL/kg ideal body weight. 1. Damage control surgery (DCS) is a technique of surgery used to care for critically ill patients. Naval War Publications 3-20.31. All resuscitation fluids and blood products must be warmed to 38.0º C or higher. Damage control surgery was described some years ago as abbreviated surgery to stop bleeding and contamination, followed by a period of ICU care before further surgery, to try to arrest the lethal triad of acidosis, hypothermia and coagulopathy.27 US military experience with combat patients is extending this concept to fluid resuscitation as well, with a tendency to give no (or only small amounts of) resuscitation fluids before haemostatic surgery. This is the first part of the damage control process whereby there are some clear-cut goals surgeons should achieve. Nonoperative treatment can be the first-line intervention for stable patients with low- or medium-grade liver, spleen, and kidney injuries. 2 Definition; History; The Lethal triad; Stages of damage control surgery; Damage Control Orthopedics; Complications of Damage Control… The different variables were systolic blood pressure below 90, hemoglobin <11 g/dL, temperature <35.5, INR > 1.5, base deficit >=6, heart rate >= 120 bpm, presence of penetrating trauma, and positive Focused Abdominal Sonography Trauma (FAST) exam. In penetrating trauma, the bleeding is often from single arteries without extensive tissue injury, and complete haemostasis can often be easily achieved. The LITFL page on damage control surgery is an excellent introduction to the subject. This is referred to by some as damage control ground zero (DC0). If the greater saphenous vein is not available, the lesser saphenous, the cephalic, or the basilic veins should be considered. Washington, DC: Department of Defense; 1996. Continuous use of convective warming devices (e.g., Bair huggers), Allows “easy access” for planned next operative intervention, At Parkland Memorial Hospital, the “Vac-Pack” dressing is employed by packing the abdomen with laparotomy pads separated from the bowel with a fluid-impervious layer (e.g., a “bogota bag or bowel bag). Final abdominal fascial closure will likely be part of the final procedure in a damage-control scenario. However, the ability to evaluate objectively the differences and then choose the one that fits your team is important. The main goal this time is to control blood loss and minimizing contamination. Damage control operations in non-trauma patients: defining criteria for the staged rapid source control laparotomy in emergency general surgery Robert D. Becher1*, Andrew B. Peitzman2, Jason L. Sperry2, Jared R. Gallaher3, Lucas P. Neff4, Yankai Sun5, Preston R. Miller5 and Michael C. Chang5 Abstract Ideally performed at 24 to 36 hours, later if indications of physiologic derangement persist, Removal of packs, with replacement if necessary. . The principles of damage control surgery defied the traditional surgical teaching of definitive operative intervention and were slow to be adopted. At this point in process the critical care team has been able to correct the physiologic derangements. Moving the patient early on, unless absolutely necessary, can be detrimental. This approach emerged after his observation that early death following trauma was associated with severe metabolic and physiologic derangements following severe exsanguinating injuries. In up to 40% of military extremity vascular injuries, the patient has a concomitant orthopedic fracture. The key is to prevent exacerbation of hemorrhaging until definitive vascular control can be achieved, the theory being that if clots have formed within a vessel then increasing the patient's blood pressure might dislodge those established clots resulting in more significant bleeding. In addition, the description illustrated how the three phases of damage control surgery can be implemented. Each of these phases has defined timing and objectives to ensure best outcomes. Damage control surgery can be divided into the following three phases: Initial laparotomy, Intensive Care Unit (ICU) resuscitation, and definitive reconstruction. CT scan upon admission can identify these patients. To help mitigate confounding variables a randomized control trial called the Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) is being performed to evaluate the transfusion requirement.. Monitor bladder pressure. Jednalo se tehdy ourgentní laparotomii, která byla prováděna vrámci resuscitační fáze ošetřování polytraumatu. , There are four main complications. 4. 2013; 656-9. As a rule abdomens should not be definitively closed until there has been radiologic confirmation that no retained objects are present in the abdomen. It was at this time that hypothermia, acidosis, and coagulopathy were described as the “trauma triangle of death” or the “bloody vicious cycle.” A fourth component, dysrhythmia, which usually heralded the patient's death, was later added by Asensio. This subsequently lets clinicians focus on reversing the physiologic insult prior to completing a definitive repair. Rather than representing a deterioration in technique or care, this likely reflects maintenance and transport of evermore severely injured patients to the hospital phase of management.7 Ongoing changes in resuscitation strategies, with a greater emphasis on matched red blood cell to plasma ratios and decreased crystalloid volumes, may prove especially beneficial in low-pressure venous injuries. Specifically the past decade has seen a paradigm shift in early resuscitation of critically injured patients. If this occurs the temporary closure device should be taken down immediately. Michael C Reade, Peter D (Toby) Thomas, in Oh's Intensive Care Manual (Seventh Edition), 2014, The International Committee of the Red Cross (ICRC) recommends as basic principles: early and thorough wound excision and irrigation, no unnecessary dressing changes, delayed primary closure, antibiotics as an adjuvant, antitetanus vaccine and immunoglobulin if necessary, no internal bone fixation, and early physiotherapy.2. In contrast, in blunt trauma, the bleeding is often venous as well as arterial, with capillary oozing into the soft tissues, which may continue for hours. Damage Control Sequence In the beginning, damage control surgery was described by the three main steps: abbreviated laparotomy, ICU resuscitation, and planned re-operation with definitive repair. Metody damage control surgery (DC) jsou dočasné, život zachraňující operace ukritického polytraumatu, které již vroce 1983 prosazoval Stone pod pojmem „zkrácená laparotomie“. Hypotension is disastrous to an already injured brain, and must not be prolonged by under-resuscitation (see Ch. Brian P. Smith, Patrick M. Reilly, in Evidence-Based Practice of Critical Care (Third Edition), 2020.  As mentioned above, it is important to obtain an abdominal radiograph to ensure that no retained sponges are left intra-operatively. If unable to oxygenate with conventinal ventilation, at Parkland Memorial Hospital we use the Volume Diffuse Respirator (VDR) as a salvage therapy. Damage control surgery can be divided into the following three phases: Initial laparotomy, Intensive Care Unit (ICU) resuscitation, and definitive reconstruction. Niten Singh, Reagan W. Quan, in Rich's Vascular Trauma (Third Edition), 2016, Conduit other than greater saphenous vein is usually not available or feasible in military or civilian scenarios of damage control surgery. Moore EE, Burch JM, Franciose RJ, Offner PJ, Biffl WL. In fact, the basis of damage control surgery rests on quick control of life-threatening bleeding, injuries, and septic sources in the appropriate patient before restoring their physiological reserves as a first step followed by ensuring of the physiological reserves and control of acidosis, coagulopathy, and hypothermia prior to complementary surgery . Damage control surgery, DCS, Abdominal compartment syndrome, ACS Bailout/damage control surgery following trauma has developed as a major advance in surgical practice in the last 20 years.  Patients who are arriving severely injured to trauma centers can be coagulopathic. The initial selective nonoperative management of blunt and penetrating abdominal trauma requires the patient to be located in an area where continuous evaluation and monitoring are possible and the eventual transfer to the operating theater is feasible and fast. Of 16 172 patients in the ICRC database, 41% required two operations, 14% three and 20% four or more.2 Serial debridement in this manner is demanding; in mass casualties or resource-poor environments, the ICRC recognises this approach may be impossible and advises wider initial excisions.2. The first step after removing the temporary closure device is to ensure that all abdominal packs are removed. Savage, Timothy C. Fabian, in Rich's Vascular Trauma (Third Edition), 2016. 2. This lets granulation occur over a few weeks, with the subsequent ability to place a split-thickness skin graft (STSG) on top for coverage. A number of different techniques can be employed such as using staplers to come across the bowel, or primary suture closure in small perforations. História [upravit | editovat zdroj]. Lucas and Ledgerwood described the principle in a series of patients. Damage control resuscitation has had a dramatic impact on how care for critically ill patients is administered. Author information: (1)Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada. There are exceptions to the ‘no primary closure’ rule. In these scenarios, exposing and controlling the vascular injury with or without the use of a vascular shunt is accomplished first. The emphasis is on injury pattern recognition (to identify patients likely to benefit from damage control), followed by DCR and rapid transfer to theatre of identified patients. All the variables were found to be predictive of the need of massive transfusion protocol except for temperature (Callcut 2013). (Note: Commercially available dressings have been made that accomplish the same goal with less “improvisation” but they are not as cost-effective.). Furthermore, it is not appropriate to generalise the evidence from penetrating trauma to blunt trauma because these two types of trauma are quite different. 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