A number of new approaches to the management of patients with major truncal or extremity trauma have evolved over the past 20 years. These include the following: minimizing time at the scene of trauma and in the emergency department; the presence of in-house attending surgeons, particularly in centers with a significant percentage of penetrating trauma; minimizing admission laboratory testing; initiating resuscitation in the operating room for patients with severe hypotension, cardiac arrest, or external hemorrhage; and early operative control of hemorrhage. All of these are now accepted as major factors in decreasing morbidity and mortality.1–4 Another major change has been the recognition that conservative operative techniques and shortened operative times, even when all organ repairs have not been completed, will increase survival in civilian and military patients with cervical, truncal, or extremity injuries and intraoperative “metabolic failure.”5–22 Finally, it has been recognized that standard closure of a thoracotomy or the midline abdominal incision is impossible to achieve in many severely injured patients, is too time-consuming in others, and may cause an abdominal compartment syndrome in the postoperative period after a laparotomy.23–33
This chapter will describe the techniques used during “damage control” operations (as named by Rotondo et al.);7 prevention and sequelae of primary or secondary abdominal compartment syndrome; the alternate techniques for closure of a thoracic, abdominal, or extremity incision in patients with major trauma;34–43 care of the patient in the surgical intensive care unit (SICU) after a damage control operation; the approach to reoperation; and late repair of incisional hernias when the abdomen has been left open at a reoperation.41,44–47
Damage control operations are performed in injured patients with profound hemorrhagic shock and preoperative or intraoperative metabolic sequelae that are known to adversely affect survival. The widely accepted three stages of damage control are:
Limited operation for control of hemorrhage and contamination. Includes control of hemorrhage from the heart or lung; conservative management of injuries to solid organs; resection of major injuries to the gastrointestinal tract without reanastomosis; control of hemorrhage from major arteries and veins in the neck, trunk, or extremities; packing of organs or spaces should a coagulopathy occur; and use of an alternate coverage or closure of a cervical incision, thoracotomy, laparotomy, or site of exploration of an extremity.
Resuscitation in the SICU. Includes vigorous rewarming of the hypothermic patient; restoration of a normal cardiovascular state by the infusion of blood, blood products, and fluids and the use of inotropic and related drugs; correction of residual coagulopathy after hypothermia is reversed; and supportive care to minimize the magnitude of acute lung injury (ALI) and acute kidney injury (AKI).
Reoperation. Includes completion of definitive repairs, search for missed injuries, and formal closure of the incision, if possible.
Clinical Recognition of Patients Likely to Need Damage Control Operations