Chapter 38: Trauma Damage Control

INTRODUCTION

Although abdominal packing and abbreviated laparotomy had been described prior to this landmark manuscript, this sentence written by H. Harlan Stone in 1983 initiated a major paradigm shift in the operative management of patients with hemorrhagic shock after trauma. Previously, injured patients with or without shock underwent similar operations. All definitive procedures were completed at a first operation or the patient died in the process. A number of papers describing the coagulopathy associated with hypothermia and metabolic acidosis in injured patients with hemorrhage were then published over the next decade.^{1,2,3,4,5,6,7,8} Simultaneously, several centers began to practice the concept of Stone’s abbreviated laparotomy and assess the results.^9,10,11,12 In 1993, Rotondo et al from the University of Pennsylvania labeled these abbreviated procedures as “damage control” surgery; also, they documented that the strategy substantially improved survival (11% vs 77%) in patients with combined abdominal visceral and vascular injuries.¹³ Originally implemented for injured patients with “metabolic failure” or “physiologic exhaustion” (hypothermia, metabolic acidosis, coagulopathy), damage control surgery quickly became a technique used by multiple surgical specialties including the following: general surgery, thoracic surgery, vascular surgery, orthopedic surgery, gynecologic surgery, etc.^{14,15,16,17,18,19,20,21,22,23,24,25,26,27}

This chapter reviews the definition, indications, and techniques of “damage control” surgery on injured patients. Emerging concepts including damage control resuscitation, thromboelastography directed infusions of blood components, and resuscitative endovascular balloon occlusion of the aorta (REBOA—see Chapter 34) will be discussed, as well.

DAMAGE CONTROL OPERATIONS: DEFINITION AND STAGES

Definition

The abbreviated laparotomy in “damage control” surgery controls bleeding and limits further contamination from the gastrointestinal tract before the patient is transferred to the intensive care unit (ICU). Although early papers described a three step process, this has been expanded to include prehospital management and closure of the abdominal incision.

Stages

Prehospital (“Ground Zero”)

The initial evaluation by prehospital personnel often initiates the damage control process. Early notification of the trauma center about the level of hemodynamic instability and magnitude of injuries can prompt mobilization of operative and/or interventional teams. Permissive hypotension will be appropriate in patients without traumatic brain injuries, and blood transfusion during transport is available in some prehospital systems.

Abbreviated Initial Operation

As noted above there are certain subsets of ...