Damage control surgery

dcs

1. DAMAGE CONTROL SURGERY

2. Etymology The term damage control was coined by US navy during WWII. Basic skill and procedure that can maintain water tight integrity and offensiveness of war ships. Similar sinking ship is a traumatized patient.

3. Definition Damage control surgery  ( DCS ) is a form of surgery typically by trauma surgeons utilized in severe unstable injuries. This form of surgery puts more emphasis on preventing the triad of death, rather than correcting the anatomy .

4. Trauma triad of death Massive hemorrhage lead to : Hypothermia Metabolic acidosis Coagulopathy

5. Hypothermia Heat loss by evaporation and conduction Inability to generate heat Central cause of all derangements.

6. Metabolic acidosis Massive transfusion Vasopressors Diminished cardiac function

7. Coagulopathy Consumption dilution Hypothermia Acidosis

8. Principles of damage control Surgery Stone insisted for rapid closure of abdomen for preventing hemorrhage. Now it is established that opening of abdomen for a long leads to loss of heat leading to hypothermia. Concomitant thoracic opening aggravates it. Try all possible methods to break the vicious cycle of lethal triad and restore physiology.

9. Steps is damage control surgery Bleeding raw surfaces, like that of the liver, are packed with laparotomy pads. Small enteric injuries are closed with staples Large ones are stapled on both sides with the GIA stapling device and the damaged segment removed.

10. Injuries of the pancreas and kidneys are not treated if they are not bleeding Clamps may be left on unrepaired vascular injuries, or the vessels are ligated. Vessels which cannot be ligated without loss of life or limb can be treated with temporary indwelling shunts.

11. No drains are placed, and the abdomen is closed with sharp towel clips placed two centimetres apart which include only the skin. Towel clips are used because they do not cause bleeding as needles do and they can be applied very rapidly, usually in 60–90 seconds. The closure of just the skin allows for the abdominal or thoracic cavities to accommodate a greater volume without increased pressure.

12. The clips are covered with a towel, and a plastic adhesive sheet is placed over the towel to prevent excessive fluid from draining onto the patient's bedding. Cold wet drapes are removed, and the patient is covered from head to toe with layers of warm blankets.

13. Definitive surgery Patient is taken for definitive surgery within 24 hours. If surgeon believes the metabolic derangements will improve within 2 hours patient can be kept in OT. If metabolic corrections will take a long time patient can be shifted to SICU .

14. Indications for definitive surgery Core temprature 36°F or above Correction of acid base balance Normalization of coagulation profile.

15. Advantages A small study on penetrating abdominal injuries showed a survival benefit over historical controls( 90%  v  58%; P=0.02 ). Mortality in Iraq war was 10% compared with 24% in Gulf war .

16. Disadvantages Sepsis and multi organ failure Pneumonia Intra abdominal abscess Enteric fistula Compartment syndrome

17. Damage control neurosurgery Arrest intracranial hemorrhage. Evacuate the hematoma. Primary closure of dura to prevent infection. Craniectomy to prevent compartment syndrome.

18. Damage control orthopedics Control all hemorrhages primarily. Avoid early manipulations of long bone fracture. Prevents fat embolism. Two hit theory .

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