Damage Control Strategy Research Articles

Vascular Injury During Urologic Surgery: Somebody Call My Mother.

To provide the critical elements to effectively manage hemorrhage from vascular injuries sustained during planned urological interventions. The frequency of intraoperative vascular injuries is increasing. However, literature concerning the management of iatrogenic operative vascular injuries is scarce. Although rare, intraoperative vascular injuries may be associated with potential catastrophic complications and death. The decision-making process following a potential life-threatening intraoperative vascular injury occurs in a very short time frame. Appropriate knowledge of the critical elements to identify the source of bleeding, initiate first-line hemostatic measures, select the candidate for damage control strategies, and perform the indicated operative repairing maneuvers and techniques have been proved crucial to ensure hemodynamic stability and bleeding cessation. The key surgical principles to counteract the impact of exsanguinating bleeding, and the aim to obtain the best achievable outcomes after definitive repair, are described in detail in this review.

Open abdomen in acute mesenteric ischemia.

In acute mesenteric ischemia, early diagnosis should optimally be followed by either open or endovascular intestinal revascularization. All too often, diagnosis is delayed and diagnosis and treatment are performed at the same time during explorative laparotomy. The majority of patients will be diagnosed when transmural intestinal infarction has developed and at this time point damage control strategies involving intestinal revascularization, bowel resection, open abdomen and second look may be necessary to salvage the patient. This review outlines the principles of the damage control surgery approach in acute mesenteric ischemia and the rationale for temporary open abdomen. In patients in need of long-term open abdomen therapy, negative pressure wound therapy with continuous fascial traction is apreferred technique achieving ahigh delayed fascial closure rate.

Treatment efficacy of damage control strategy in elderly patients with multiple injuries combined with thoracic trauma

Objective To investigate the efficacy of damage control strategy in treating elderly patients with multiple injuries combined with thoracic trauma and evaluate its efficacy. Methods A retrospective case-control study was performed to analyze the data of 877 elderly patients with multiple injuries combined with thoracic trauma admitted from January 2005 to December 2016. There were 574 males and 303 females, aged 65-94 years (mean, 70.8 years). The patients were divided into damage control group (n=406) and non-damage control group (n=471), according to the application of damage control strategy. The injury severity score (ISS) of the damage control group and the non-damage control group were (14.4±8.5)points and (13.7±9.4)points, respectively. The emergency operation rate within 24 hours, the blood loss during emergency operation, the thoracic and abdominal surgery, vascular interventional embolization, thoracic fracture and limb pelvic fracture operation within 72 hours, as well as ICU treatment rate, treatment time, complications, and prognosis were compared between the two groups. Results Fifty-one cases (12.6%)in the damage control group and 93 cases (19.7%)in the non-damage control group underwent emergency operation within 24 hours(P 0.05), the incidence of arrhythmia and heart failure were 53.4% and 60.5% (P<0.05), and the incidence of respiratory failure and ARDS were 17.7% and 23.8% (P<0.05). A total of 29 cases died in the damage control group (7.1%) and 53 cases died in the non damage control group (11.3%) (P<0.05). Conclusions Damage control strategy should be applied to treating elderly patients with multiple injuries combined with chest injury. By simplifying or reducing emergency surgery, active ICU treatment, and focusing on the fixation of chest fractures, damage control strategy can effectively reduce complications and improve survival rate. Key words: Aged; Multiple trauma; Thoracic injuries; Damage control

Impact of emergency physicians competent in severe trauma management, surgical techniques, and interventional radiology on trauma management.

AimDespite recent advancements in trauma management following introduction of interventional radiology (IVR) and damage‐control strategies, challenges remain regarding optimal use of resources for severe trauma.MethodsIn October 2014, we implemented a trauma management system comprising emergency physicians competent in severe trauma management, surgical techniques, and IVR. To evaluate this system, of 5,899 trauma patients admitted to our hospital from January 2011 to January 2018, we selected 107 patients with severe trauma (injury severity score ≥ 16) who presented with persistent hypotension (two or more systolic blood pressure measurements <90 mmHg), regardless of primary resuscitation. Patients were divided according to the date of admission: Conventional (January 2011–September 2014) or Current (October 2014–January 2018). The primary end‐point was in‐hospital mortality. Secondary end‐points included time from arrival to start of surgery/IVR.ResultsThere were 59 patients in the Conventional group and 48 in the Current group. Although patients in the Current group were more severely ill compared with those in the Conventional group, mortality in the Current group was significantly lower (Conventional 64.4% versus Current 41.7%, P = 0.019), especially among patients whose first intervention was IVR (Conventional 75.0% versus Current 28.6%, P = 0.001). Time from arrival to initiation of surgery/IVR was shorter in the Current group (Conventional 71.5 [53.8–130.8] min versus Current 41.0 [26.0–58.5] min, P < 0.0001).ConclusionsThis trauma management system based on emergency physicians competent not only in severe trauma management, but also surgical techniques and IVR, could improve outcomes in patients with severe multiple lethal trauma.

Perforated Diverticulitis with Generalized Peritonitis: Low Stoma Rate Using a "Damage Control Strategy".

Optimal surgical management of perforated diverticulitis of the sigmoid colon has yet to be clearly defined. The purpose of this study was to evaluate efficacy of a "Damage Control Strategy" (DCS). Patients with perforated diverticulitis of the sigmoid colon complicated by generalized peritonitis (Hinchey III and IV) surgically treated according to a damage control strategy between May 2011 and February 2017 were enrolled in the present multicenter retrospective cohort study. Data were collected at three surgical centers. DCS comprises a two-stage concept: [1] limited resection of the perforated colon segment with oral and aboral blind closure during the emergency procedure and [2] definitive reconstruction at scheduled second laparotomy (anastomosis ∓ loop ileostomy or a Hartmann's procedure) after 24-48 h. Fifty-eight patients were included into the analysis [W:M 28:30, median age 70.1years (30-92)]. Eleven patients (19%) initially presented with fecal peritonitis (Hinchey IV) and 47 patients with purulent peritonitis (Hinchey III). An anastomosis could be created during the second procedure in 48 patients (83%), 14 of those received an additional loop ileostomy. In the remaining ten patients (n = 17%), an end colostomy was created at second laparotomy. A fecal diversion was performed in five patients to treat anastomotic complications. Thus, altogether, 29 patients (50%) had stoma at the end of the hospital stay. The postoperative mortality was 9% (n = 5), and median postoperative hospital stay was 18.5days (3-66). At the end of the follow-up, 44 of 53 surviving patients were stoma free (83%). The use of the Damage Control strategy leads to a comparatively low stoma rate in patients suffering from perforated diverticulitis with generalized peritonitis.

Damage control surgery in perforated diverticulitis: ongoing peritonitis at second surgery predicts a worse outcome.

Damage control strategy (DCS) is a two-staged procedure for the treatment of perforated diverticular disease complicated by generalized peritonitis. The aim of this retrospective multicenter cohort study was to evaluate the prognostic impact of an ongoing peritonitis at the time of second surgery. Consecutive patients who underwent DCS for perforated diverticular disease of the sigmoid colon with generalized peritonitis at four surgical centers were included. Damage control strategy is a two-stage emergency procedure: limited resection of the diseased colonic segment, closure of oral and aboral colon, and application of a negative pressure assisted abdominal closure system at the initial surgery followed by second laparotomy 48h later. Therein, decision for definite reconstruction (anastomosis or Hartmann's procedure (HP)) is made. An ongoing peritonitis at second surgery was defined as presence of visible fibrinous, purulent, or fecal peritoneal fluid. Microbiologic findings from peritoneal smear at first surgery were collected and analyzed. Between 5/2011 and 7/2017, 74 patients underwent a DCS for perforated diverticular disease complicated by generalized peritonitis (female: 40, male: 34). At second surgery, 55% presented with ongoing peritonitis (OP). Patients with OP had higher rate of organ failure (32 vs. 9%, p= 0.024), higher Mannheim Peritonitis Index (25.2 vs. 18.9; p= 0.001), and increased operation time (105 vs. 84min., p= 0.008) at first surgery. An anastomosis was constructed in all patients with no OP (nOP) at second surgery as opposed to 71% in the OP group (p< 0.001). Complication rate (44 vs. 24%, p= 0.092), mortality (12 vs. 0%, p= 0.061), overall number of surgeries (3.4 vs. 2.4, p= 0.017), enterostomy rate (76 vs. 36%, p= 0.001), and length of hospital stay (25 vs. 18.8days, p= 0.03) were all increased in OP group. OP at second surgery occurred significantly more often in patients with Enterococcus infection (81 vs. 44%, p= 0.005) and with fungal infection (100 vs. 49%, p= 0.007). In a multivariate analysis, Enterococcus infection was associated with increased morbidity (67 vs. 21%, p< 0.001), enterostomy rate (81 vs. 48%, p= 0.017), and anastomotic leakage (29 vs. 6%, p= 0.042), whereas fungal peritonitis was associated with an increased mortality (43 vs. 4%, p= 0.014). Ongoing peritonitis after DCS is a predictor of a worse outcome in patients with perforated diverticulitis. Enterococcal and fungal infections have a negative impact on occurrence of OP and overall outcome.

Use of interventional radiology as initial hemorrhage control to improve outcomes for potentially lethal multiple blunt injuries

IntroductionRecently, trauma management has been markedly improved with interventional radiology (IVR) and damage-control strategies. However, the indications for its use in hemodynamically unstable patients with severe trauma remains unclear. In some cases, IVR may be more effective than surgery for damage-control hemostasis; however, performing IVR in life-threatening trauma settings is challenging. To address this, we practiced and evaluated a trauma-management system with emergency physicians who trained for both severe trauma management, and techniques of surgery and IVR. Materials and methodsAmong the 1822 patients with severe trauma admitted between October 2014 and December 2016, 201 underwent emergency surgery or IVR. Among these, 16 patients whose systolic blood pressure was ≤90 mmHg, without improvement following primary resuscitation, and whose first intervention was IVR, were analyzed. We retrospectively evaluated the admission characteristics, IVR-related characteristics, and prognoses, and compared several parameters before and after IVR. ResultsThis study included 10 men and 6 women (median age: 46 years). IVR was performed for 10 pelvic fractures; five liver-, one splenic-, and one renal injury; and one transection each of the external carotid-, vertebral-, axillosubclavian-, intercostal-, and lumbar arteries. The mean times from the patient arrival, and diagnosis to the start of IVR were 56.3 ± 26.6 and 15.1 ± 3.8 min, respectively. The mean time spent in the angiography suite was 50 min. The systolic blood pressure, pulse rate, base excess/deficit, serum-lactate levels, and D-dimer values were significantly improved after IVR. Although two patients needed additional treatment for morbidities following IVR intervention, all achieved complete recovery. The mortality rate was 25.0%, and no preventable deaths were noted. Eight patients showed unexpected survival. ConclusionsIn some cases, IVR may be the best first measure for resuscitative hemostasis in potentially lethal multiple injuries, given efficient diagnoses/actions and the ability to deal with complications.

I principali insetti parassiti della pioppicoltura italiana: aggiornamenti e prospettive

Abstract: The main insect pests affecting poplar plantations in Italy: updates and perspectives. An update of the main insect pests causing significant damage to poplar plantations in Italy is here provided. The recent introduction of a few highly dangerous invasive alien pests as well as the increasing importance of secondary pests infesting poplar trees physiologically stressed by climate change are discussed. A short comment about induced damage and possible control strategies is provided for each pest.

Resuscitation thoracotomy

Resuscitation thoracotomy is a rarely performed procedure whose use, in France, remains marginal. It has five specific goals that correspond point-by-point to the causes of traumatic cardiac arrest: decompression of pericardial tamponade, control of cardiac hemorrhage, performance of internal cardiac massage, cross-clamping of the descending thoracic aorta, and control of lung injuries and other intra-thoracic hemorrhage. This approach is part of an overall Damage Control strategy, with a targeted operating time of less than 60minutes. It is indicated for patients with cardiac arrest after penetrating thoracic trauma if the duration of cardio-pulmonary ressuscitation (CPR) is <15minutes, or <10minutes in case of closed trauma, and for patients with refractory shock with systolic blood pressure <65mm Hg. The overall survival rate is 12% with a 12% incidence of neurological sequelae. Survival in case of penetrating trauma is 10%, but as high as 20% in case of stab wounds, and only 6% in case of closed trauma. As long as the above-mentioned indications are observed, resuscitation thoracotomy is fully justified in the event of an afflux of injured victims of terrorist attacks.

Paris Terrorist Attack on November 13, 2015 - Applying Wartime In-hospital Triage and Damage Control Strategies

Paris Terrorist Attack on November 13, 2015 - Applying Wartime In-hospital Triage and Damage Control Strategies

Perihepatic Paking as the First Stage of Damage Control Strategy (Review)

Severe liver injury in victims with abdominal trauma is followed by high rate of complications and mortality. Technical equipment of the operating rooms, highly skilled surgeons and modern resuscitation aids allow to use resection technique with high frequency of favorable outcomes and form an ambiguous attitude to the perihepatic packing. The results of severe liver injuries management by using of different surgical approaches were reviewed. Also, an evolution of the views on the problem of liver tamponade for severe trauma was presented. We have tried to allocate the current role of perihepatic packing in liver injuries management.

Chest trauma: “Damage Control” Begins in the emergency room

Background: Patients with severe thoracic injuries and subsequent physiological decline may not be candidates for initial definitive treatment. Despite limited data, this subset of patients may benefit from the implementation of thoracic damage control, which should begin in the emergency room. Methods: A literature search was conducted through Medline following PRISMA guidelines. Articles that focused on damage control surgery, the use of damage control techniques in traumatic injuries, and the use of damage control in civilian populations were selected. Due to the paucity of literature and lack of Level I evidence on this subject, studies published in any year were considered. Results: A search of the literature yielded 119 studies. Most of these were excluded based on inclusion and exclusion criteria. Thirty-five articles were selected for review. The majority of these were classified as Level III, IV, or V evidence. Limitations: Limitations of this article are similar to all PRISMA-guided review articles: The dependence on previously published research and availability of references. Conclusion: Effective “Damage Control” following a traumatic injury begins with initial management in the emergency department, which is followed by an abbreviated operation, equally aggressive critical care, and a planned reexploration. Additional studies are required to examine the adaptation of specific damage control techniques to thoracic injuries, but patients with severe chest trauma can benefit from initiation of damage control strategies in the emergency room.

Partial Zone II Resuscitative Endovascular Balloon Occlusion of the Aorta in Management of Multiple Trauma with Combined Abdominal and Pelvic Injury

Introduction: Resuscitative endovascular balloon occlusion of the aorta has been used in various clinical settings to elevate blood pressure in the setting of shock, even if the evidence base is weak with no clear indications. Case presentation: We report a case of traumatic hemorrhagic shock in which this technique was used in an unusual manner, treating obvious arterial abdominal bleeding associated with suspected pelvic arterial bleeding, in a Trauma Center where hybrid angiographic-surgical suite is not available. A 35-year-old man was involved in a traffic accident within 2 trucks. He was transported to the Major Trauma Center of an Integrated Trauma System where emergent laparotomy confirmed massive hepatic rupture and a bleeding control was obtained by large abdominal packing. Trauma team decided to considerate Resuscitative Endovascular Balloon Occlusion of the Aorta, positioning a deflated balloon in zone III to eventually manage a pelvic arterial hemorrhage, while performing Bogota Bag. Suddenly a new abdominal arterial bleeding was noted through Bogota Bag. Because Pringle maneuver was considered too difficult in this case because of liver hilum injury, the balloon was moved cranially with the aim to reach zone I. Introducer sheath displacement occurred at this time, and the balloon was then only partially inflated in zone II, usually considered too dangerous, and immediately the target systolic blood pressure of 90 mmHg was obtained. Transfer the patient into interventional radiology suite was then feasible and embolization of active bleeding by right hepatic artery and superior mesenteric artery branch, missed during first laparotomy, were performed. Balloon was definitely deflated after 50 minutes. The patient was discharged by the hospital 113 days later, fully recovered with long lasting motor rehabilitation program. Discussion: Partial zone II Resuscitative Endovascular Balloon Occlusion of the Aorta in this particular case allowed overcoming procedural mistakes without major complications and with good clinical outcome. Conclusion: Judicious manage of REBOA inflation time and amount, together with multidisciplinary contemporary damage control strategy with clear and effective team leading, is the key to effectively resuscitate multiple trauma shocked patients.

An updated-Lagrangian damage mechanics formulation for modeling the creeping flow and fracture of ice sheets

An updated-Lagrangian formulation is developed to model the incompressible Stokes (creeping) flow and fracture of ice sheets using both explicit-integral and implicit-gradient nonlocal damage approaches. The governing equations of incompressible nonlinearly viscous Stokes flow assuming the plane strain approximation are discretized using high-order mixed finite elements over the current reference domain. The discretized nonlinear system is solved using a Picard iteration scheme, and a mesh update method is employed to obtain the updated reference domain at every time step. Fracture (crevasse) initiation and propagation is modeled using a scalar (isotropic) damage variable, and damage control or element removal strategies are implemented to avoid numerical accuracy and convergence issues arising from fully damaged finite elements near the crevasse tip. The formulation is implemented in the open-source finite element software FEniCS, and the relevant numerical algorithms are detailed. Numerical verification and benchmark studies based on manufactured nonlinear Stokes solutions and constant velocity and gravity-driven creep flow experiments are conducted to establish the viability of the formulation. We demonstrate that crevasse propagation rates obtained from nonlinear Stokes and Maxwell viscoelastic models are in good agreement over short time scales (days), so it is reasonable to neglect the elastic effects and employ the Stokes model to simulate iceberg calving. Furthermore, we demonstrate that over long time scales (months) the updated-Lagrangian Stokes formulation is more physically accurate than the total Lagrangian Maxwell viscoelastic formulation because the former accounts for the domain geometry changes. To conclude, the merit of the proposed formulation is two-fold: first, it is computationally more efficient than the Maxwell viscoelastic model; and second, it accounts for finite strain creep deformations accruing over long time scales.

Development of Novel Criteria of the "Lethal Triad" as an Indicator of Decision Making in Current Trauma Care: A Retrospective Multicenter Observational Study in Japan.

To evaluate the utility of the conventional lethal triad in current trauma care practice and to develop novel criteria as indicators of treatment strategy. Retrospective observational study. Fifteen acute critical care medical centers in Japan. In total, 796 consecutive trauma patients who were admitted to emergency departments with an injury severity score of greater than or equal to 16 from January 2012 to December 2012. None. All data were retrospectively collected, including laboratory data on arrival. Sensitivities to predict trauma death within 28 days of prothrombin time international normalized ratio greater than 1.50, pH less than 7.2, and body temperature less than 35°C were 15.7%, 17.5%, and 15.9%, respectively, and corresponding specificities of these were 96.4%, 96.6%, and 93.6%, respectively. The best predictors associated with hemostatic disorder and acidosis were fibrin/fibrinogen degradation product and base excess (the cutoff values were 88.8 µg/mL and -3.05 mmol/L). The optimal cutoff value of hypothermia was 36.0°C. The impact of the fibrin/fibrinogen degradation product and base excess abnormality on the outcome were approximately three- and two-folds compared with those of hypothermia. Using these variables, if the patient had a hemostatic disorder alone or a combined disorder with acidosis and hypothermia, the sensitivity and specificity were 80.7% and 66.8%. Because of the low sensitivity and high specificity, conventional criteria were unsuitable as prognostic indicators. Our revised criteria are assumed to be useful for predicting trauma death and have the potential to be the objective indicators for activating the damage control strategy in early trauma care.

Atraumatic splenic rupture cases presenting with hemorrhagic shock and coagulopathy treated by splenic artery occlusion using a microballoon catheter before splenectomy

Atraumatic splenic rupture (ASR) is an uncommon pathologic condition in which bleeding from the spleen occurs for a variety of nontraumatic reasons. While the current trend in traumatic splenic rupture is nonoperative management including transcatheter arterial embolization, the current recommendation for the treatment of most patients with ASR is splenectomy. In this report, we describe two cases of ASR presenting with hemorrhagic shock and complicated by anticoagulation therapy. In patients with severe hemorrhagic shock and coagulopathy, a damage control strategy is recommended. Our successful treatment of these patients included a three-step strategy as a damage control: (i) rapid transient hemostasis by splenic artery occlusion using a microballoon catheter, (ii) damage control resuscitation and (iii) splenectomy as a definitive hemostatic treatment.

Management of abdominal sepsis--a paradigm shift?

The abdomen is the second most common source of sepsis and secondary peritonitis. The most common causes of abdominal sepsis are perforation, ischemic necrosis or penetrating injury to the abdominal viscera. Management consists of control of the infection source, restoration of gastrointestinal tract (GI) function, systemic antimicrobial therapy and support of organ function. Mortality after secondary peritonitis is still high. Excluding patient-related factors such as age or co-morbidities that can not be influenced at the time of intervention, delay to surgical intervention and inability to obtain source control are the main determinants of outcome. In patients with severe physiological derangement or difficult intraperitoneal conditions, where a prolonged operation and complete anatomical repair may not be possible or appropriate, it is becoming increasingly popular to utilize a damage control strategy with abbreviated laparotomy and planned reoperations. The main components of damage control laparotomy for secondary peritonitis are postponing the reconstruction of intestinal anastomoses to a second operation (deferred anastomosis) and leaving the abdomen open with some form of temporary abdominal closure (TAC). Advances in the management techniques of the open abdomen and new negative pressure-based TAC-devices have significantly reduced the previously observed prohibitive morbidity associated with open abdomens. These advancements have led to current fascial closure rates after TAC approaching 90%. The cornerstones of appropriate antimicrobial therapy are the timing, spectrum and dosing of antibiotics. Enteral nutrition should be started as soon as possible in hemodynamically stable patients but withheld when the patient is on a significant dose of vasopressors or whenever GI hypoperfusion is suspected. Timely source control with appropriate use of antimicrobial agents and early intensive care offers the best chance of survival for patients with abdominal sepsis. The introduction of the concept of damage control to the management of secondary peritonitis represents a paradigm shift in the same way as in management of major trauma. Although limited and repeated surgical interventions have been shown to be safe, the actual benefits need to be demonstrated in controlled studies.

Maxillofacial and neck trauma: a damage control approach.

Severe maxillofacial and neck trauma exposes patients to life threatening complications such as airway compromise and hemorrhagic shock. These conditions require rapid actions (diagnosis and management) and a strong interplay between surgeons and anesthesiologists. Effective airway management often makes the difference between life and death in severe maxillofacial and neck trauma and takes initial precedence over all other clinical considerations. Damage control strategies focus on physiological and biochemical stabilization prior to the comprehensive anatomical and functional repair of all injuries. Damage control surgery (DCS) can be defined as the rapid initial control of hemorrhage and contamination, temporary wound closure, resuscitation to normal physiology in the intensive care unit (ICU) and subsequent reexploration and definitive repair following restoration of normal physiology. Damage control resuscitation (DCR) consists mainly of hypotensive (permissive hypotension) and hemostatic (minimal use of crystalloid fluids and utilization of blood and blood products) resuscitation. Both strategies should be administered simultaneously in all of these patients.

Pelvic trauma and vascular emergencies.

Pelvic ring injuries carry a high mortality rate, the main cause of which, in the first 24hours, is exsanguination. Injured patients are managed by a multidisciplinary damage-control strategy. Unstable patients should have instrumentalized hemostasis without delay. Arterial embolization is an effective way of achieving this and justifies this approach being permanently available in level1 trauma-centers. After CT assessment of injuries, stable patients can undergo arterial embolization if active arterial bleeding or vascular damage is present. The embolization methods (selective or unselective) and agents used depend on the patient's hemodynamic stage and assessment of the injury whenever possible.

Damage Control Surgery for Hepatocellular Cancer Rupture in an Elderly Patient: Survival and Quality of Life.

Spontaneous rupture of hepatocellular carcinoma (HCC) is a rare emergency condition with high mortality rate. Successful management depends on patients' hemodynamic condition upon presentation and comorbidities, correct diagnosis, HCC status, liver function, and future liver remnant, as well as available sources. There is still a debate in the literature concerning the best approach in this devastating complication. Nevertheless, the primary goal should be a definitive bleeding arrest. In most cases, patients with spontaneous rupture of HCC present with hemodynamic instability, due to hemoperitoneum, necessitating an emergency treatment modality. In such cases, transcatheter arterial embolization (TAE) should be the treatment of choice. Emergency liver resection is an option when TAE fails or in cases with preserved liver function and limited tumors. Otherwise, damage control strategies, as in liver trauma, are a reasonable alternative. We report a case of an elderly patient with hemoperitoneum and hypovolemic shock from spontaneous rupture of undiagnosed HCC, who was treated successfully by emergency surgery and damage control approach.