During World War II, the U.S. Navy recognized the importance of damage control strategies and published a manual (Handbook of Damage Control) to ensure ships remained serviceable in battle to the fullest extent possible.1 The term “damage control,” as it is currently used in surgery, originated in a paper by Rotondo et al. in 1993.2 This report described a reduction in mortality in patients with severe penetrating abdominal injury. Rather than performing the “definitive laparotomy” at the index operation, a “damage control” approach was implemented. Therefore, rapid surgical control of vascular injury and hemorrhage was accomplished in conjunction with control of fecal contamination. Definitive repairs were delayed until the patient underwent significant resuscitation and stabilization outside of the operative room (OR). During this period, correction of coagulopathy, acidosis, and hypothermia could be accomplished and definitive surgical management planned. Antecedent publications included work by Stone et al. in 1983 describing rapid intra-abdominal packing and termination of laparotomy at the onset of apparent intraoperative coagulopathy with return to OR after resuscitation and stabilization.3 Multiple other studies have further refined damage control strategies and techniques establishing the foundation for this surgical maneuver.4–13 Damage control surgery is now widely practiced and the application of damage control principles are implemented in the most severely injured trauma patients. In vascular surgery, damage control strategies focus on rapid hemorrhage control and temporary restoration of end-organ perfusion in order to mitigate the effects of ischemia while other life-threatening injuries are managed.
The Global War on Terrorism led to widespread use of damage control strategies and techniques. Eastridge et al. reported that hemorrhage was the principal physiologic insult attributed to the battlefield mortality in patients with potentially survivable injuries.14 As a result of this sentinel report, damage control vascular surgery was pushed far-forward to the point of injury resulting in increased focus on pre-hospital tourniquet use and temporary intravascular shunt utilization.15–19 Overall, damage control strategies contributed significantly to successful limb salvage and patient survival.20–28
This chapter will focus on damage control techniques relevant to vascular surgery, including resuscitation, hemorrhage control, temporary intravascular shunting (TIVS), fasciotomy, and resuscitative endovascular balloon occlusion of the aorta (REBOA).
GENERAL PRINCIPLES OF DAMAGE CONTROL SURGERY AND RESUSCITATION
Broadly, the term “damage control” describes surgical and resuscitative strategies to stabilize life-threatening physiology before definitive surgical restoration of anatomy and function, which can be delayed. Damage control can be conceptualized in the framework of several triads: trauma’s lethal triad, the three phases of damage control surgery, and three key tenets of damage control resuscitation (Fig. 6-1).
Organizational tenets of damage control intervention
Trauma’s lethal triad consists of the vicious cycle of hypothermia, acidosis, and coagulopathy. Acidosis ...