Principles for Damage Control in Military Casualties

Abstract

Conceptually, damage control principles are rooted in military origins; the surgical application is analogous to US Navy terminology for “the capacity of a ship to absorb damage and maintain mission integrity” [16]. The interval termination of an operation has been described with liver packing as early as 1908; however, the practice was ended soon after high infectious rates were identified [8]. The introduction of a formal laparotomy by World War I improved mortality; however, the essence of damage control surgery was further captured in World War II, as exploratory laparotomy became the standard of care for penetrating abdominal trauma, and surgeons gained vast experience in comprehending the necessity for expedited abdominal exploration hemodynamically unstable patients [8]. Specifically, in the Western desert in 1942, Watts highlighted that a war surgeon “must evacuate the wounded with all possible speed, both to clear the unit and to restore its mobility…that he must wherever possible, avoid the procedures that will prevent the early evacuation of the patient” [8]. This resonated on the battlefield; however, it wasn’t until 1983 that Dr. Harlan Stone, a civilian, reinstituted rapid packing and termination of the laparotomy in civilian trauma patients when intraoperative coagulopathy became excessive [8]. Ten years later, Rotondo specifically termed the phrase “damage control surgery” where patients that underwent damage control surgery with two or more visceral injuries and/or had a major vascular injury had a markedly higher survival in a small nonrandomized cohort [77% (10 of 13) vs. 11% (1 of 9), p < 0.02]. Currently, more recent publications have demonstrated an improved 30-day survival [73.6% vs. 54.8%; p = 0.009] and a decreased mean trauma intensive care unit [11 v 20 days; p = 0.01] stay in patients receiving a massive transfusion that underwent damage control laparotomy and damage control resuscitation [9]. Although this methodology to appropriately care for severely injured civilian patients would appear to extrapolate well to an austere environment, the transition to military austere environments was initially questioned by many.