Damage Control Surgery and Resuscitation in Patients Sustaining a Severe Injury

Introduction

The immediate treatment provided to a patient with severe injuries upon arrival at the hospital can be explained under damage control surgery and resuscitation. Resuscitation (reviving the unconscious patient when) is done before the surgical intervention. This procedure is an essential component of trauma care in the modern era. Damage control surgery mainly aims at attending to the life-threatening condition first, thereby keeping the patient stable to continue with the definitive management of other non-life-threatening injuries. In addition, it mainly aims to reduce further damage, prevent blood loss, and keep the patient stable. Further restoration of the anatomy can be carried out in subsequent treatments.

What Are Damage Control Surgery and Resuscitation?

• Damage control surgery is a treatment procedure for physiological (functional) recovery rather than anatomic reconstruction.

• In addition, hypotensive resuscitation and blood products to prevent lethal triads of three risky conditions are called damage control resuscitation.

The Lethal Triad:

1. Hypothermia - Decreased body temperature, inability to maintain metabolic energy resulting in peripheral vasoconstriction, metabolic acidosis, and end-organ dysfunction.

2. Coagulopathy - The impaired ability of blood to form clots that are caused due to hypoperfusion (reduced amount of blood flow) is called coagulopathy.

3. Acidosis - Excess acid in the body is called acidosis, which can lead to changes in cardiac function.

• Damage control surgery and damage control resuscitation are performed together. At first, resuscitation is performed, followed by damage control surgery.

What Are the Main Objectives of Damage Control Surgery and Resuscitation?

• Damage control is the shift from the conventional surgical focus of anatomical restoration to the restoration of normal function.

• Taking proper measures to control life-threatening factors and contamination.

• Localize and minimize the damage as it occurs.

• Access emergency management as quickly as possible.

What Are the Various Phases of Damage Control Surgery?

It is a three-phase technique later modified by adding a different phase.

Phase Zero:

1. Identification of proper damage patterns and early evacuation (shifting the patient to the hospital) for emergency management is the primary step.

2. Next, sequence induction of anesthesia, intubation, early rewarming, and administering intravenous antibiotics and tetanus prophylaxis are done in the emergency department. Temporary control of bleeding is carried out with the help of topical hemostatic agents (agents to reduce bleeding) in managing large soft tissue injuries with small vessel bleedings.

3. Early resuscitation and replacement of blood, plasma, and platelets will prevent the patient from major risks. Shifting to the operating theater, complete phase zero of damage control surgery.

Phase One:

Phase one begins on arrival in the operating theater, and an immediate incision of the abdomen (laparotomy) is carried out. The patient is shifted to an Intensive care unit.

Operating Room Procedures:

1. Abbreviated surgery (laparotomy) is carried out to help maintain blood components and temperature and prevent blood clotting.

2. Anesthesia aims to establish a proper airway, maintain oxygenation, decrease the temperature, and prevent clotting disturbances.

3. In abdomen the rapid celiotomy (also called laparotomy - a large incision in the abdomen) is done in which the controlling the bleeding, removing the contamination by primary repair or external drainage, and temporarily closing the abdomen with vacuum-assisted dressings.

4. Thoracic and rapid control of bleeding and air leaks is necessary in case of thoracic damage. Its management is a unique challenge as the damage to organs in the thorax cannot be managed through temporary treatments. Heart - rapid repair; lung - thoracotomy; food pipe (esophagus) - diversion and drainage.

5. Vascular is divided into two categories of repair:

• Simple Repair - It includes lateral repair like ligation and placement of temporary shunts.

• Complex Repair- It includes vascular reconstructions like graft placements, rapid repair, and ligation.

6. Orthopedic is done in certain cases where pulmonary complications due to delayed femoral repair pave the way for damage control orthopedics (DCO). Long bones can be treated by temporary external fixation.

7. Neurosurgery is done for modulation of pressure in the cranium (skull).

In an unstable patient, diagnostic x-rays may be required.In addition, X-rays are taken after intubation to confirm correct tube placement, which, when wrongly placed, can lead to patient death even before entering the operation theater.

• Phase Two - Physiological and biochemical (blood and fluids) stabilization is achieved in the intensive care unit (ICU).

• Phase Three - Thisis carried out after the functional abnormalities have been resolved. The patient is brought to the operating theater for definitive surgical management to fix all injuries and anatomic reconstruction.

What Are the Indications of Damage Control Surgery?

• Only selective patients require damage control surgery, like patients with major injuries.

• Though the patient's clinical conditions vary in major injuries, there is no precise yardstick to categorize patients with severe injuries to undergo damage control surgery and resuscitation. Delay in the decision to undergo surgery, the lesser the positive outcome.

• Patients with vascular (blood vessels) and visceral (internal organs) damage.

• Those incapable of tolerating the prolonged operative procedure.

• Treatment for intra-abdominal sepsis and abdominal compartment syndrome (increased pressure in the abdomen).

What Are the Requirements for Damage Control Surgery?

• Multiple mass casualties.

• Multisystem trauma.

• Open pelvic (hip bone) fracture.

• Major abdominal injury.

What Is the Outcome of Damage Control Surgery?

• Acute respiratory distress syndrome (a condition in which there is fluid accumulation in the air sacs).

• Multi-organ failure.

• Death.

• Sepsis (a complication of an infection).

• Pulmonary contusion (injury to the walls of lungs).

What Are the Complications of the Damage Control Surgery and Resuscitation?

• Intra-abdominal abscess formation (infection) in the abdomen.

• Enteric fistula (open connection from the stomach or intestine to the external environment).

• Inability to close the edges of the wound.

• Abdominal compartment syndrome.

• External fixation in bony fractures can lead to pin site infections.

• Vascular damage control surgeries can lead to graft infections.

Conclusion

Healthcare professionals should be aware of all the damage control principles and procedures, as they can save many patients' lives. Although this concept was introduced in the earlier days, it has shown positive outcomes in patients since then. Using modern techniques with better expertise has minimized the complications and contributed to reducing fatalities. Not only in major trauma cases, damage control surgery and resuscitation have been used in the treatment of various other conditions also. It is hoped that future developments will pave the way for the treatment of many conditions with the help of damage control surgery and resuscitation.