Reviewed and revised 5 August 2015
- Damage control surgery, along with permissive hypotension and hemostatic resuscitation, is integral to the concept of damage control resuscitation
- Damage control surgery involves limited surgical interventions to control haemorrhage and minimize contamination until the patient has sufficient physiological reserve to undergo definitive interventions
- This strategy was derived from military experience and is now increasingly adopted into civilian trauma management
DAMAGE CONTROL RESUSCITATION
- Damage control resuscitation (DCR) is a systematic approach to the management of the trauma patient with severe injuries that starts in the emergency room and continues through the operating room and the intensive care unit (ICU)
- DCR involves haemostatic resuscitation, permissive hypotension (where appropriate) and damage control surgery
- DCR aims to maintain circulating volume, control haemorrhage and correct the ‘lethal triad’ of coagulopathy, acidosis and hypothermia until definitive intervention is appropriate
RATIONALE FOR DAMAGE CONTROL SURGERY
- Management of the metabolic derangement of ongoing bleeding supersedes the need for definitive surgery
- Abbreviated operations that control haemorrhage and contain spillage from the alimentary and urogenital tracts
- Rapid transfer to ICU for correction of acidosis, coagulopathy and hypothermia (ongoing haemostatic resuscitation)
- Definitive operation is deferred
- These operations tend to have a high complication rate
- Survival is given preference over morbidity
- maintenance of normothermia
- less coagulopathy
- fewer products used overall, despite increase in pre- and intra-operative blood product use
- may produce decreased ALI, MODS, ARDS and improve survival
STAGES OF DAMAGE CONTROL RESUSCITATION
- must be approached from all services (pre-hospital, ED, anaesthesia, surgery, ICU, haematology)
- early transfusion to maintain circulating volume
- minimisation of crystalloid use
- reduce coagulopathy
- keep warm
- prevent acidemia
Rapid movement to the operating theatre (OT)
- “scoop and run” approach
- address immediate life threats prehospital or in the emergency department
- permissive hypotension may be tolerated in penetrating vascular trauma pending surgical repair
- avoid unnecessary delays in transit to the OT
- short time in OT
- limited focused surgery to control haemorrhage and decontaminate
- partially resect organs
- staple off and remove injured bowel
- fibrin sealants
- leave abdomen open
Move to ICU
- restore near normal physiology
- correct lethal triad: rewarm, correct acidosis and correct coagulopathy
- optimize ventilation
- plan re-operation once stable
Re-operation at 24-36 hours
- remove packs
- definitive surgery
- formally close abdomen
- new onset or uncontrolled surgical bleeding
- abdominal compartment syndrome
- inability to wake and wean
- non-life threatening injuries not dealt with or missed (needs secondary survey/full examination)
References and Links
- Ball CG. Damage control resuscitation: history, theory and technique. Can J Surg. 2014;57:(1)55-60. [pubmed]
- Beuran M, Iordache FM. Damage control surgery–new concept or reenacting of a classical idea? J Med Life. 2008 Jul-Sep;1(3):247-53. PMC3018967.
- Cirocchi R, Montedori A, Farinella E, Bonacini I, Tagliabue L, Abraha I. Damage control surgery for abdominal trauma. Cochrane Database Syst Rev. 2013 Mar 28;3:CD007438. PMID: 23543551.
- Blackbourne LH. Combat damage control surgery. Crit Care Med. 2008 Jul;36(7 Suppl):S304-10. doi: 10.1097/CCM.0b013e31817e2854. PMID: 18594257.
- Midwinter MJ. Damage control surgery in the era of damage control resuscitation. J R Army Med Corps. 2009 Dec;155(4):323-6. PMID: 20397611.
- Parr MJ, Alabdi T. Damage control surgery and intensive care. Injury. 2004 Jul;35(7):713-22. PMID: 15203312.
- Rotondo MF, Schwab CW, McGonigal MD, et al. ‘Damage control’: an approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma. 1993;35:(3)375-82; discussion 382-3. PMID: 8371295
FOAM and web resources
- Trauma.org — Damage control surgery
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.