Learn from the Care of the Combat Victim: Ask the Surgeons to Consider Damage Control Surgery for the Bleeding Patient



Learn from the Care of the Combat Victim: Ask the Surgeons to Consider Damage Control Surgery for the Bleeding Patient


Surjya Sen MD



Damage control surgery is defined as operative management that employs a staged approach to the severely injured patient. It seeks to avoid “physiologic burnout” seen with the lethal triad of hypothermia, acidosis, and coagulopathy. Definitive therapy for the patient’s problem or injury is deferred to give preference to the stopping of hemorrhage and the control of contamination by using the simplest and most rapid means possible. Temporary wound closure methods are employed initially, with a plan to return the patient to the operating room after physiologic abnormalities have been corrected (or at least stabilized) in an intensive care setting.


HISTORICAL PERSPECTIVE

Traditionally, it was believed that the operative management of a patient should provide definitive care even if the physiologic condition of a patient was deteriorating (especially if the physiologic deterioration was due to a problem that was the focus of the operation). In the early 1900s, this dogma was challenged in management of battlefield victims with exsanguinating injuries. J. H. Pringle introduced the techniques for the temporization of hepatic hemorrhage for trauma by using liver packs and vascular compression. However, because of poor outcomes, these techniques fell out of favor until the 1970s and 1980s, when they were reintroduced with “abbreviated laparotomies.” These procedures were used to temporize the source of bleeding in trauma victims so that they could return later to the operating room, after their coagulopathies had been corrected. By the 1990s, damage control surgery (coined by Rotondo in 1993) had gained popularity not only for application toward soldiers in combat settings, but also for trauma victims in civilian settings.


APPLICABILITY TO NONCOMBAT SITUATIONS

Although damage control surgery offers evident advantages in a combat situation (faster evacuation times, better use of limited resources, and more efficient management of a large number of casualty victims who may present simultaneously), it also has applicability in civilian traumas. Abbreviated
surgeries allow the surgical, anesthesia, and intensive care teams to steer clear of irreversible physiologic end points such as uncontrolled hemorrhage from disseminated intravascular coagulopathy. Avoiding life-threatening abnormalities such as hypothermia, coagulopathy, and acidosis are the primary end points for the care providers. Once these have been met, the patient is returned to the operating room for definitive management.

Jul 1, 2016 | Posted by in ANESTHESIA | Comments Off on Learn from the Care of the Combat Victim: Ask the Surgeons to Consider Damage Control Surgery for the Bleeding Patient
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