Additionally numerous retrospective studies have shown the effectiveness of vein as a conduit in extremity trauma. Damage control surgery. The Three stages of damage control are as follows: Control of hemorrhage and contamination. The emphasis is on injury pattern recognition (to identify patients likely to benefit from damage control), followed by DCR and rapid transfer to theatre of identified patients. In these scenarios, exposing and controlling the vascular injury with or without the use of a vascular shunt is accomplished first. - opísali triádu smrti; 1993 Rotondo a Schwab - termín DCS; 2001 Assensio a kol. This approach, now called “damage control,” describes it as multiphasic, where reoperation occurs after correcting physiologic abnormalities. Keen reviewed the experience with autologous vein repair in extremity injury (n = 134) in a busy trauma setting and estimated that it required nearly 10 minutes to harvest and prepare the conduit. The idea is that the coolers would continue to be delivered to the location where the patient is being treated until the trauma team leader (typically the trauma surgeon) would discontinue the order  Certain factors have been looked at by Callcut and colleagues to determine the predictive ability of patients arriving at trauma centers. 4. First is hemorrhage control, second is contamination control, third is evaluation or diagnosis, and fourth is reconstruction. Hematology Am Soc Hematol Educ Program. The approach to caring for such critically ill patients is dependent on nurses, surgeons, critical care physicians, operating room staff, blood bank personnel, and administrative support. Blood … The intensivist is critical in working with the staff to ensure that the physiologic abnormalities are treated. Following massive transfusion exceeding two blood volumes in trauma and emergency surgery, severe physiologic derangement ensued and mortality was found to be greater than 60%. Vascular shunting may be employed in extremities using surgical shunts, such as a Javid shunt or large-bore IV tubing. ScienceDirect ® is a registered trademark of Elsevier B.V. ScienceDirect ® is a registered trademark of Elsevier B.V. URL: https://www.sciencedirect.com/science/article/pii/B9780323052269500207, URL: https://www.sciencedirect.com/science/article/pii/B9780323028448500615, URL: https://www.sciencedirect.com/science/article/pii/B9781455712618000084, URL: https://www.sciencedirect.com/science/article/pii/B9780702047626000746, URL: https://www.sciencedirect.com/science/article/pii/B9780702047626000850, URL: https://www.sciencedirect.com/science/article/pii/B9780323044189500631, URL: https://www.sciencedirect.com/science/article/pii/B9780323640688000833, URL: https://www.sciencedirect.com/science/article/pii/B9781455712618000175, URL: https://www.sciencedirect.com/science/article/pii/B9781455712618000126, URL: https://www.sciencedirect.com/science/article/pii/B9781455712618000187, Critical Care Secrets (Fifth Edition), 2013, Craig Olson MD, Alexander L. Eastman MD, in, Multitrauma, Including Peripheral Compartment Syndrome, Massimo Antonelli, ... Anselmo Caricato, in, Vascular Disruption and Noncompressible Torso Hemorrhage, Jonathan J. Morrison, Joseph J. DuBose, in, Oh's Intensive Care Manual (Seventh Edition), Michael C Reade, Peter D (Toby) Thomas, in, EXSANGUINATION: RELIABLE MODELS TO INDICATE DAMAGE CONTROL, Current Therapy of Trauma and Surgical Critical Care. Advanced modes of mechanical ventilation may be necessary for patients with packed thoraces. Furthermore, traumatic brain injury is often present in blunt trauma, which frequently involves several body regions. 75, section on Traumatic brain injury – emergency treatment).24–26. Packing with radiopaque laparotomy pads allow for the benefit of being able to detect them via x-ray prior to definitive closure. The initial selective nonoperative management of blunt and penetrating abdominal trauma requires the patient to be located in an area where continuous evaluation and monitoring are possible and the eventual transfer to the operating theater is feasible and fast. While this lifesaving method has significantly decreased the morbidity and mortality of critically ill patients, complications can result.  This technique places emphasis on preventing the "lethal triad", rather than correcting the anatomy. Several studies have demonstrated that vein grafts are prone to undergoing transmural necrosis when they are placed in a contaminated field without adequate or viable soft-tissue coverage.  Once hemorrhage control is achieved one should quickly proceed to controlling intra-abdominal contamination from hollow-viscus organs. Gifford and colleagues provided one of the only studies to characterize longer-term extremity outcomes following the use of temporary vascular shunts. The first is controlling hemorrhage followed by contamination control, abdominal packing, and placement of a temporary closure device. Typical resuscitation strategies have used an approach where aggressive crystalloid and/or blood product resuscitation is performed to restore blood volume. Controlling of hemorrhage as discussed above is the most important step in this phase. Stage I of damage control surgery is where the patient is taken to the operating theater and undergoes minimal and necessary surgical operations [ 13, 14, 15 ]. In fact, data suggests that around 25% of patients arrive having coagulopathy. . Jonathan J. Morrison, Joseph J. DuBose, in Rich's Vascular Trauma (Third Edition), 2016, Damage control surgery (DCS) is a strategy originally described in the context of exsanguinating abdominal trauma, where the completeness of operative repair is sacrificed in order to limit physiologic deterioration.14,15 This technique has been extended to include other body regions.16 Definitive operative repair is then completed in a staged fashion following resuscitation and warming in the intensive care unit. The following goes through the different phases to illustrate, step by step, how one might approach this. Regardless of which method one decides to use it is important that the abdominal fascia is not reapproximated. Even apparently clean wounds should not be closed before 4–5 days. damage control surgery within the combat theater during the acute surgical, postoperative intensive care stabilization, reoperation, and evacuation phases. Damage control surgery, DCS, Abdominal compartment syndrome, ACS Certain pitfalls have also become evident, one of which is the potential to develop abdominal compartment syndrome (ACS). Each of these phases has defined timing and objectives to ensure best outcomes. Damage Control Surgery Brett H. Waibel Michael F. Rotondo I. This typically requires close monitoring in the intensive care unit, ventilator support, laboratory monitoring of resuscitation parameters (i.e., lactate). Despite changes in prehospital care and patient transport, open surgical and interventional repair, Conduit other than greater saphenous vein is usually not available or feasible in military or civilian scenarios of, Journal of the American College of Surgeons, International Journal of Surgery Case Reports. A number of different techniques can be employed such as using staplers to come across the bowel, or primary suture closure in small perforations. From: Critical Care Secrets (Fifth Edition), 2013, Craig Olson MD, Alexander L. Eastman MD, in Parkland Trauma Handbook (Third Edition), 2009. 4 The three stages were described as mentioned in the subsequent text. For the emergency services, truncated scene times and early notification of the receiving hospital trauma team are the priorities; ‘scoop and run’ rather than ‘stay and play’. Solid organ injury (i.e., spleen, kidney) should be dealt with by resection. Trauma surgery typically has four stages. Vessels that are able to be ligated should, and one should consider shunting other vessels that do not fall into this category. In addition, damage control surgery has been extrapolated for use in general, vascular, cardiac, urologic, and orthopedic surgery. Attention is then turned to performing the necessary bowel anastomosis or other definitive repairs (i.e., vascular injuries). In many circumstances, especially trauma patients, require that other specialties address a variety of injuries. In up to 40% of military extremity vascular injuries, the patient has a concomitant orthopedic fracture. In addition, the description illustrated how the three phases of damage control surgery can be implemented. Once this is complete the abdomen should be packed. This concept fits well with the ICRC basic principles and, as it requires general rather than specialist surgical expertise, can be performed in small hospitals close to the wounded. This was the first article that brought together the concept of limiting operative time in these critically ill patients to allow for reversal of physiologic insults to improve survival. Base deficit >8 mEq/L or worsening base deficit. In addition to having the right team in place is having a prepared team. Coagulopathy, acidosis, and hypothermia make the prolonged and definitive operative management of trauma patients dangerous. As such, the philosophy of damage control continues to be appealing within the realm of CCC, since encompassed within the contingencies of the modern Most of the time, circumstances such as patient positioning, other injuries, or indwelling intravenous lines exclude exposure and procurement of these alternative vein conduits. The key is to prevent exacerbation of hemorrhaging until definitive vascular control can be achieved, the theory being that if clots have formed within a vessel then increasing the patient's blood pressure might dislodge those established clots resulting in more significant bleeding. These patients clearly have a hernia that must be fixed 9 to 12 months later. undergoing damage control surgery (DCS). How should trauma patients be managed in the intensive care unit?  Finally fascial dehiscence has been show to result in 9–25% of patients that have undergone damage control surgery.. Damage control surgery can be divided into the following three phases: Initial laparotomy, Intensive Care Unit (ICU) resuscitation, and definitive reconstruction. The main goal this time is to control blood loss and minimizing contamination. To many, including the editors of this text, the finding of 10 minutes is conservative. Of 16 172 patients in the ICRC database, 41% required two operations, 14% three and 20% four or more.2 Serial debridement in this manner is demanding; in mass casualties or resource-poor environments, the ICRC recognises this approach may be impossible and advises wider initial excisions.2. Delay definitive repair of injury including time-consuming anastomoses and ostomies.  The approach would provide a limited surgical intervention to control hemorrhage and contamination. If bowel edema prevents this, several techniques (e.g., Wittman patch) can be employed to help reapproximate fascial edges in stages. However, the ability to evaluate objectively the differences and then choose the one that fits your team is important. 1. This has been reported as high as 83%. 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