Damage control surgery: An alternative approach for the management of critically injured patients

Abstract

Over the past 20 years, it has gradually become apparent that the results of prolonged and extensive surgical procedures performed on critically injured patients are often poor, even in experienced hands. The triad of hypothermia, coagulopathy, and metabolic acidosis effectively marks the limit of the patient's ability to cope with the physiological consequences of injury, and crossing this limit will frustrate even the most technically successful repair. These observations have led to the development of a new surgical strategy that sacrifices the completeness of immediate repair in order to adequately address the combined physiological impact of trauma and surgery. This approach is unfolded in three phases. During the initial operation, the surgeon carries out only the absolute minimum necessary to rapidly control exsanguination and prevent the spillage of intestinal contents and urine into the peritoneal cavity. Packing represents the traditional method for the management of major liver injuries. The second phase consists of secondary resuscitation in the intensive care unit, characterized by maximization of hemodynamics, correction of coagulopathy, rewarming, and complete ventilatory support. During the third phase, the intra-abdominal packing is removed and definitive repair of abdominal injuries is performed. The "damage control" concept has been shown to increase overall survival and is likely to modify the management of the critically injured patient.