The principal features of DCR are listed in Table 5.2. These features address the components of the “bloody vicious cycle,” also called the “triangle of death”; these are coagulopathy, acidosis, and hypothermia (1, 2). While these threats are most often linked to severe trauma, severe systemic inflammation can result in the same alterations, albeit without the loss of red cells from the circulation.

Periodically, these alterations result in a self-perpetuating pathophysiology that will not respond to ongoing operating room management. Survival depends upon interrupting the “bloody vicious cycle.” DCR as well as damage control surgery (DCS) serve to accomplish that task (3).

The combination of data gathered in recent military conflicts and civilian experience supports the early administration of fresh frozen plasma (FFP) and platelets for patients suffering with life-threatening hemorrhage resulting from trauma. While the abdominal cavity is the primary site for bleeding of this magnitude, the same advantage is anticipated for patients with chest, pelvic, and/or extremity injuries (3, 4).

Anticipation of coagulopathy is important, especially since FFP must be thawed before administration. For trauma, the report of persistent hypotension in the field and during transport as well as hypotension and initiation of blood transfusion at a referring facility can serve as sufficient prompts to initiate a massive transfusion protocol that includes early release of FFP and platelets. In the Emergency Department, hypotension (<110 mm Hg) and a positive focused assessment with sonography for trauma (FAST) for abdominal fluid are indicative of life-threatening hemorrhage. Similarly, hypotension with a pelvic fracture and evidence of active hemorrhage on computed tomography (CT) scan or active bleeding in the thoracic cavity can prompt early use of FFP and platelets.

Acidosis at or below a pH of 7.2 can result in hemodynamic and coagulation disturbances. The principal etiology is inadequate oxygen delivery to meet cellular oxygen demand resulting in anaerobic glycolysis and lactic acid production. In addition, the use of large volumes of 0.9% saline often results in a hyperchloremic state that can aggravate metabolic acidosis (see chap. 7) (3).

Despite the known adverse effects from inadequate oxygen delivery, some aspects of resuscitation management remain controversial, especially the timing and completeness of reversing oxygen supply deficits prior to control of active hemorrhage. While the magnitude and duration of inadequate oxygen delivery and the resultant oxygen debt have been shown to be directly associated with the severity of cell and organ injury (see chap. 2), vigorous resuscitation to normal hemodynamic values may exacerbate uncontrolled hemorrhage.

Permissive hypotension (systolic blood pressure <85 mm Hg) is the strategy employed to allow some improvement in oxygen delivery while not accentuating hemorrhage. Using this
subnormal endpoint of resuscitation, fluid and blood product administration is provided in small volumes, or not at all, until definitive control of the bleeding site is accomplished. This strategy can support perfusion of vital organs while limiting ongoing blood loss from uncontrolled injuries.

The application of permissive hypotension is best supported in the setting of penetrating injury, particularly cardiac wounds, and with short pre-hospital transport and, thereby, short preoperative times. At present, no consensus guidelines are available for other trauma or hemorrhagic conditions, but a similar approach would seem applicable to isolated extremity hemorrhage or ruptured intra-abdominal aneurysm (3, 5).

The management of hypothermia, especially in trauma patients, is not controversial. Preventing and reversing hypothermia is a consideration that must begin in the field and continue from the Emergency Department, to the operating room, and into the intensive care unit. Warm blankets, warmed fluid and blood products, external warming devices, lavage of body cavities with warm saline, and extracorporal blood warming have all been effectively utilized, demonstrating that warming is beneficial to overall patient outcome. The method(s) employed should be linked to the severity of the hypothermia and the associated physiologic derangements. The most rapid and aggressive technique is extracorporal blood warming (6, 7, 8, 9).

The components of DCL are listed in Table 5.3. DCL may be planned at the outset of abdominal exploration or may become a requisite as the “bloody vicious cycle” blossoms during the surgery. Packing is the usual first step for hemorrhage control, with attention subsequently directed to “surgical” bleeding, that is, sites that can be readily addressed by clamping, ligation, and sometimes removal. In blunt trauma, the surgical sites will most often be the spleen and mesenteric vasculature. For penetrating trauma, any site may demand a direct approach, with ligation of venous structures and shunting versus repair of arterial structures. Recognition of hemorrhage at sites not amenable to direct surgical approach (pelvic and deep hepatic regions) can prompt on-table angioembolization. If on-table angioembolization is not an option, then abdominal packing for hemorrhage control, temporary coverage of the abdominal viscera, and transport to the angiography suite should be considered (3).

Control of a perforated hollow viscus may be achieved with sutures, staples, or resection of the site with plan for delayed re-establishment of intestinal continuity. Intraluminal tube drainage is another option if tissue cannot be apposed.

The options for leaving the abdomen open are several, from closing the more mobile skin with towel clips to the application of a vacuum device. No clinical data support one choice over the other (10). Interestingly, peritoneal negative pressure therapy seems more effective in a model of intraperitoneal sepsis, possibly by removing inflammatory ascites (11).

In 2004, the World Society of the Abdominal Compartment Syndrome developed a consensus definition that included the following: intra-abdominal hypertension (IAH) as an intra-abdominal pressure (IAP) ≥12 mm Hg and ACS as a sustained IAP ≥20 mm Hg that is associated with new organ dysfunction or failure. In addition, abdominal perfusion pressure (APP) was defined as mean arterial pressure (MAP) minus IAP (12). APP <60 mm Hg is worrisome for ACS even when IAP is <20 mm Hg (13).

IAH has been catalogued into four grades on the basis of measured pressure (Table 5.4) (12). ACS has been classified as either primary (a result of intra-abdominal or retroperitoneal pathology) or secondary (a result of abdominal region edema and/or ascites related to resuscitation). Common etiologies of primary and secondary ACS are listed in Table 5.5.

IAP is usually measured using the urinary bladder via a Foley catheter (14, 15).