Damage control surgery is defined as the rapid initial control of hemorrhage and contamination, temporary abdominal closure, resuscitation to normal physiology in the ICU, and re-exploration and definitive repair after normal physiology has been restored. Damage control techniques can be applied in vascular, thoracic, orthopedic, and neurosurgical procedures.

 

Phase 0 (Ground 0): Prehospital and Early Resuscitation
The early recognition of patients who are at risk of developing the lethal triad and those in whom damage control techniques may be indicated
1. Stop bleeding using tourniquets or direct pressure
- If the patient has noncompressible bleeding, practice permissive hypotension
2. Rapid transfer to the medical treatment facility
3. Initiate damage control resuscitation
- Prevent hypothermia
- Measure blood gases
4. Rapid transfer to the OR
Consider resuscitative balloon occlusion of the aorta(REBOA)—if trained and available. (Only if proper surgical service available within 10- 15 minutes) REBOA is a bridge to surgical control of hemorrhage in the OR

 

Phase 1: Primary Damage Control Operation
1. Control of hemorrhage: Hemorrhage from blood vessels can be controlled by ligation, shunting, or repair of injured vessels as they are encountered. The initial goal is hemorrhage control, not maintenance of blood flow. For the patient in extremis, clamping or shunting of major vessels is recommended over repair. Additional methods of hemorrhage control include balloon catheter tamponade of vascular or solid viscus injuries.
2. Determine extent of injury
3. Control of contamination: Contamination control also proceeds as injuries are encountered, utilizing clamps, primary repair, or resection without reanastomosis.
4. Therapeutic packing
5. Temporary abdominal closure
Damage control laparotomy. Perform only essential resections or pack solid organs to diminish blood loss.
Rapidly terminate the procedure to minimize hypovolemia, hypothermia, acidosis, and coagulopathy.
Perform definitive reconstruction only during operation after the patient has stabilized and can tolerate a prolonged operation.
 

Phase 2: Critical Care
Physiological support in the post-op DCS patient is paramount to survival.
1. Core rewarming: Warmed resuscitative fluids, blankets, ventilator air, and environment, or commercially available products, such as Bair Hugger, ChillBuster.
2. Reversal of acidosis: Appropriate resuscitation with blood products, colloids, and/or crystalloid.
3. Reversal of coagulopathy: Factor replacement.
4. Ventilatory support: Using ARDSNet low tidal volume support, avoiding barotrauma.
5. Injury identification: Perform a tertiary survey of the patient, obtain CT scans and angiography as indicated.
6. Monitor for ACS: ACS is a condition in which increased intraabdominal pressure adversely affects the circulation/ventilation, and threatens the function and viability of the viscera. Any patient who has undergone a massive transfusion, major resuscitation for severe trauma or large body surface area burn, or prolonged trauma laparotomy is at risk for development of ACS. A high index of suspicion must be maintained, even in postoperative patients with open abdomen. Measurement of bladder pressure is a good variable to test and follow; however, intervention for ACS should occur when suspected or clinically indicated.
- Occurs in abdominal trauma accompanied by visceral swelling, hematoma, or abdominal pack use.
Body Functions with ACS:
1. Cardiac output and venous return are decreased.
2. Reduction in blood flow to the liver, intestines, and kidneys can result in anuria.
3. Central venous, pulmonary capillary wedge, and right atrial pressures increase with intraabdominal pressure (can lead to false pulmonary artery catheter pressures).
 

Phase 3: Planned Reoperation
1. Packs should be left in place until the patient’s hemodynamics are stable and all major sites of hemorrhage have had time to clot. When removed, packs should be taken out slowly with plans for vascular control.
2. Reoperation should be scheduled when the probability of achieving definitive organ repair and complete fascial closure are highest, although an estimation that the fascia cannot be closed should not prevent initial findings. 
3. Reexploration must occur after correction of hypotension, acidosis, hypothermia, and coagulopathy. It typically occurs 24–48 hours following the initial operation. Timing can, however, be dictated by other pressing clinical concerns, such as ACS, limb ischemia, and suboptimal control of spillage at primary operation.
This surgery may occur (and in many cases should occur) at the next echelon of care.
STRATEVAC (strategic evacuation) should be weighed carefully because surgery is not available in transit.

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