Damage control: Concept and implementation

Background Hemorrhagic shock(HS) is one of the major causes of death and disability. Clinical investigation demonstrates that the prognosis of HS patients seems correlated with the strategies applied for resuscitation. However, treatments that can effectively improve the recovery of HS are still absent. Objective To review the treatment of HS with damage control resuscitation(DCR). Content DCR is a new integrated strategy, and has been used in a wide variety of surgeries, including trauma emergency treatment, cardiac surgery, obstetric surgery, etc. HS is commonly seen in patients with trauma-associated coagulopathy, hypothermia, and acidosis, because of the disturbed blood coagulation. DCR recommends permissive hypotension, hemostatic resuscitation, and damage control surgery in the treatment of HS. It not only improves the recovery of HS, but also helps reduce risk of shock-related complications. Trend DCR is a potential treatment for HS, while further investigations are required to optimize the procedures. Key words: Hemorrhagic shock; Damage control resuscitation; Hemostatic resuscitation

In some groups of polytrauma patients, particularly those with chest injuries, head injuries, and those with mangled extremities, early total care of major bone fractures may be potentially harmful. Delaying all orthopaedic surgery, however, is also not always the best approach. In these situations, damage control orthopaedics, which emphasizes the stabilization and control of the injury rather than repair will add little additional physiologic insult to the patient and is a treatment option that should be considered.

Background: Hemorrhagic trauma is a major preventable cause of mortality in critically injured patients. Rapid surgical interventions are essential for hemostasis. Comprehensive critical care management before and after surgery significantly enhances the patient survival. Damage control resuscitation (DCR) concept has been adapted from the damage control method of the United States Navy, which outlines immediate temporary measures to prevent a ship from sinking, followed by the definitive repair of the ship at a dock.Current Concepts: DCR combined with damage control surgery focuses on controlling life-threatening hemorrhages and preventing trauma-induced coagulopathy. Key aspects of this strategy are: (1) Permissive hypotension (avoiding excessive fluid resuscitation to reduce re-bleeding risk), (2) restricted fluid and hemostatic resuscitation (limiting fluids and using blood products to promote coagulation), (3) use of antifibrinolytics (administering tranexamic acid to inhibit fibrinolysis and stabilize clots), (4) hypothermia prevention (maintaining normothermia to promote coagulation and mitigate acidosis), (5) calcium maintenance (maintaining normal calcium levels for proper cardiac function and coagulation), and (6) use of vasopressors (for stabilizing blood pressure and tissue perfusion). By integrating these aspects, DCR effectively controls immediate bleeding and overcomes systemic physiological challenges, thereby improving the survival of patients with severe trauma.Discussion and Conclusion: Implementation of DCR with surgical interventions as a bundle of care effectively manages hemorrhagic trauma, possibly saving the patient. Therefore, DCR is a cornerstone strategy to improve the survival of patients with hemorrhagic trauma.

Damage control resuscitation (DCR) of the massively bleeding trauma patient comprises early intervention with blood products to replete intravascular volume, restore tissue oxygenation, and correct coagulopathy until surgical hemostasis can be achieved. Blood product resuscitation in the emergency department (ED), and also in the prehospital setting, must be coordinated, prompt, multifaceted, and evidence-based and should incorporate the appropriate use of laboratory tests and adjunct therapies, which facilitate DCR and damage control surgery. Hemostatic resuscitation should also address the management of the acute and delayed complications of massive transfusion including electrolyte imbalances, interstitial edema, acidosis, and hypothermia.

Traffic polytrauma can be considered as a 'disease of the 21st century'. It is the most common cause of death between young people from one to 44 years of age. Polytrauma has an epidemic character and also large-scale economic impact, as many as 16% of overall disability belongs to trauma. There are variety of polytrauma definitions, but it is regarded as an illness because, as such, it can be predicted, prevented and treated. Modern organizational and therapeutic polytrauma management is based on the principles of 'damage control resuscitation' and 'damage control surgery' and has contributed to lowering mortality rates from 40% to 20% in the last 25 years.

Significance: In trauma care, extensive surgical intervention may be required. Damage control surgery (DCS) is applicable to patients with life or limb-threatening conditions that are incapable of tolerating a traditional surgical approach. Recent Advances: The current resuscitation strategy for complex trauma patients includes limiting crystalloid fluids, balanced mass transfusion protocols, permissive hypotension, and damage control resuscitation. Recent technological advancements in surgical critical care have improved outcomes in these critically ill patients. Critical Issues: DCS, which is often required in patients with trauma injuries, is typically followed by surgical correction of the injury once the immediate patient survival procedures have been completed. However, DCS and the subsequent injury repair procedures have a high risk for postsurgical complication development. Future Directions: Negative pressure therapy modalities can offer clinicians additional adjunctive and cost-effective tools for the management of the trauma care patient, as these systems can be utilized during both the DCS and the postoperative injury management phases of trauma care.

War surgery and transfusion in makeshift hospitals in beleaguered cities

(iii) An update on the systemic response to trauma

RDCR Symposium fifth-year anniversary edition: global prehospital care rooted in a history of military innovation.

Although the use of damage control surgery for blunt and penetrating injury has been widely reported and defined, the use of damage control surgery on the battlefield (combat damage control surgery) has not been well detailed. Damage control surgery is now well established as the standard of care for severely injured civilian patients requiring emergent laparotomy in the United States. The civilian damage control paradigm is based on a "damage control trilogy." This trilogy comprises an abbreviated operation, intensive care unit resuscitation, and a return to the operating room for the definitive operation. The goal of damage control surgery and the triology is avoidance of irreversible physiological insult termed the lethal triad. The lethal triad comprises the vicious cycle of hypothermia, acidosis, and coagulopathy. Although the damage control model involves the damage control trilogy, abbreviated operation, intensive care unit resuscitation, and definitive operation, all in the same surgical facility, the combat damage control paradigm must incorporate global evacuation through several military surgical facilities and involves up to ten stages to allow for battlefield evacuation, surgical operations, multiple resuscitations, and transcontinental transport. Combat damage control surgery represents many unique challenges for those who care for the severely injured patients in a combat zone.

BackgroundCurrently, damage control surgery (DCS) employing multiple-staged laparotomy (MSL) is a standard hemostatic approach for treating trauma patients with unstable hemodynamics attributable to massive hemoperitoneum. Based on these findings, we had frequently employed MSL as a part of our hemostatic strategy for the patients, but with unsatisfactory outcomes. On the other hand, with the establishment of damage control resuscitation (DCR), it has become possible to avoid trauma-induced coagulopathy and to achieve adequate hemostasis with single-staged laparotomy (SSL). Consequently, our institutional strategy for surgical hemostasis of the patients has gradually shifted from MSL to SSL with implementation of DCR. The purpose of the study is to evaluate the impact of this shift in the strategy by comparing outcomes of the patients between those underwent MSL and those underwent SSL employing propensity score matching.MethodsThis retrospective, single-center, observational study evaluated outcomes of hemodynamically unstable patients with traumatic massive hemoperitoneum requiring surgical intervention between 2005 and 2020. The patient population was divided into two groups: a SSL group and a MSL group. Propensity score matching was used to adjust for differences in baseline characteristics in the two groups, a one-to-one matched analysis using nearest-neighbor matching was performed based on the estimated propensity score of each group. The primary outcome was in-hospital mortality, and secondary outcomes were 48-h mortality and 28-day mortality.ResultsA total of 170 patients met the inclusion criteria; 141 patients underwent SSL, and 29 underwent MSL. In the propensity-matched analysis with 27 pairs, the SSL group had significantly lower in-hospital mortality (odds ratio [OR] 0.154; 95% confidence interval (CI) 0.035 to 0.682) and 28-day mortality (OR 0.200; 95% CI 0.044 to 0.913) than the MSL group, but the 48-h mortality did not differ significantly between the two groups (25.9% vs. 44.4%; OR 0.375; 95% CI 0.099–1.414).ConclusionsSingle-staged laparotomy may be an effective surgical treatment for the traumatic massive hemoperitoneum cases with hemodynamic instability, if conducted following sufficient damage control resuscitation and performed by an experienced surgeon.

Trauma is a major health issue all over the world and is associated with a high rate of death and disability in both developed and developing countries.There has been a dramatic change in the management of trauma patients in the last two decades.The term damage control resuscitation and damage control surgery came into light during the last 20 years.Physician involvement is increased in trauma victims' care as the physiological derangements, maintenance of hemodynamics, and infection control are equally catastrophic for the patient, so the focus is shifted to the intensive care unit (ICU) from the operating room (OR).The objective of this article is to emphasize the role and importance of trauma intensivists in the management of polytrauma patients.Trauma intensive care is a new horizon for anesthesiologists who can manage trauma in association with a trauma surgeon, and their role will increase day by day with the advancement of imaging techniques and interventional radiology.To summarize, the duties and responsibilities of a trauma intensivist start with pre-hospital care and transport to damage control resuscitation with ABC care, maintaining hemodynamic, inter-hospital transport, preparing for damage control surgery, postoperative resuscitation, respiratory support, pain management, follow-up, and rehabilitation.

Ballistic Trauma presents complex and potentially hazardous challenges during the perioperative period. This requires the anaesthetist in conjunction with the rest of the trauma team to provide early and aggressive care in order to initially stabilise and later restore normal physiology. The lethal triad of acidosis, hypothermia and coagulopathy can significantly influence and worsen an already perilous clinical picture. The concepts of damage control resuscitation (DCR) address the thorough and careful integration of both anaesthesia and surgery to effectively deal with this lethal triad [1]. The delivery of anaesthesia in ballistic trauma is a careful combination of tailored resuscitation, analgesia and sedation. The various aspects of DCR and damage control surgery (DCS) are described in detail in separate chapters. This chapter will therefore concentrate on anaesthetic elements, with an emphasis on airway management, induction and maintenance of anaesthesia and a dedicated section focussing on analgesia.

The leading cause of preventable death in trauma is uncontrolled bleeding. Some of these deaths may be secondary to the Acute Coagulopathy of Trauma, which is present in 30% of patients on admission to hospital. In recent years, Damage Control Resuscitation has been developed, which aims to give a hemostatic resuscitation and avoid deaths caused by bleeding. This strategy considers control of bleeding with damage control surgery or interventional procedures, early transfusion of all blood products, permissive hypotension and limited use of crystalloids. Several studies have reported that early transfusion of all blood products, with a ratio close to 1:1, may be associated with lower mortality and less requirements of total transfusions in trauma patients at risk of massive bleeding and massive transfusion. These findings must be corroborated in randomized controlled trials, along with determining the optimum ratio between blood products. In stable patients, a restrictive transfusion strategy is safe and appropriate.

(iv) The initial assessment and early management of patients with severe pelvic ring injuries