Damage Control Techniques Research Articles

Traumatic Duodenal Injury: Current Management Update

Although duodenal injuries are a rare entity of all trauma, they carry high risk of morbidity and mortality. The management of duodenal injuries should encompass a multidisciplinary approach. Optimal operative management of duodenal injuries has evolved in the last few decades. Isolated duodenal injuries are rare due to its proximity to major vascular and organ structures. Immediate mortality from duodenal injuries is due to hemorrhage from major vascular injuries. Non-operative management of isolated low-grade classification of duodenal injuries is accepted with close clinical and laboratory monitoring of patients. When operative management is necessary, recent evidence suggests simple repair over complex reconstructions that carry less morbidity and improved outcomes. When dealing with injuries to the duodenopancreas complex, reconstruction of the pancreaticobiliary system should involve expertise of hepatobiliary surgeons. Management of duodenal injuries and its complications should engage a multidisciplinary approach. Damage control techniques should be utilized in patients in extremis with associated major vascular injuries. Low-grade duodenal injuries may be monitored closely with clinical examinations and laboratory values. When duodenal repair is needed, conservative repair techniques over complex reconstructions should be utilized.

A clinical series of packing the wound tract for arresting traumatic hemorrhage from injuries of the lung parenchyma as a feasible damage control technique

BackgroundTractotomy has become the standard of care for transfixing through-and-through lung injuries as it can be performed quickly with little blood loss and a low risk of complications. However, packing with laparotomy pads could be a feasible alternative to tractotomy on selected patients. We describe a series of four patients with lung trauma in which packing of the pulmonary wound tract was used as the primary and unique surgical strategy for arresting hemorrhage from injuries of the lung parenchyma.MethodsPacking of the traumatic tract is achieved by gently pulling a laparotomy pad with a Rochester clamp and adjusting it to the cavity to stop the bleeding. The pack is removed in a subsequent surgery by moistening and tractioning it softly to avoid additional damage. The operation is completed by manual compression of the wounded lobe. We present a case series of our experience with this approach.ResultsFrom 2012 to 2016, we treated four patients with the described method. The mechanism was penetrating in all them. The clinical condition was of exsanguinations with multiple sources of hemorrhage. There were three patients with peripheral injuries to the lung and one with a central injury to the pulmonary parenchyma. Bleeding was stopped in all the cases. Three patients survived. A patient had recurrent pneumothorax which was resolved with a second chest tube.ConclusionPacking of the traumatic tract allowed rapid and safe treatment of transfixing through-and-through pulmonary wounds in exsanguinating patients under damage control from several bleeding sources.

Terrorist threat: Creating a nationwide damage control training program for non-trauma care providers

IntroductionThe current terrorist threat challenges nations to train numerous non-trauma care providers with different backgrounds in damage control (DC) strategies. The purpose of this work was to propose a specific DC training program. MethodsA Task Force of 16 civilian and military physicians met for a 24-hour session, to propose the construction of a DC training program for non-specialised caregivers. ResultsExisting DC training programs are heterogeneous, mainly theoretical and almost only for physicians. A program entitled Damage Control for Terrorist Attack Victims (DC-TAV) was then proposed. Identified training targets were care providers from prehospital and hospital staffs, with no experience in trauma care. The training objectives were the improvement of individual and collective skills in managing terrorist attacks casualties. The tools selected for training concerned e-learning on a dedicated digital teaching platform (including a core section of four modules with types and mechanisms of injury, basic DC techniques, triage, organisation of emergency medical response and two complementary modules for doctors with DC resuscitation including remote transfusion and DC surgery), hands-on workshops with procedural simulation and full-scale simulation exercises, technical (tourniquets, haemostatic gauzes, needle thoracostomy, chest tube drainage, management of airway, coniotomy) and non-technical (leadership, communication, coordination and triage, decision-making, appropriate use of resources) skills. Finally, an evaluation of the DC-TAV program was planned. ConclusionsThe DC-TAV program is an ambitious, civilian-military, nationwide and long-term program, based on a harmonised standard of care and including multidimensional training. Further studies are required to assess its efficacy.

Clinical implementation of the Humacyte human acellular vessel: Implications for military and civilian trauma care.

The incidence of wartime vascular injury has increased and is a leading cause of mortality and morbidity. While ligation remains an option, current resuscitation and damage control techniques have resulted in vascular repair being pursued in more than half of wartime injuries. Options for vascular reconstruction are currently limited to autologous vein or synthetic conduits, choices which have not changed in decades, both of which have problems. Autologous vein is preferable but requires time to harvest and may not be available. Synthetic grafts are poorly resistant to infection and associated with thrombotic complications. Recognizing this capability gap, the US Combat Casualty Care Research Program has partnered with academia and industry to support the development and clinical introduction of a bioengineered human acellular vessel. This human acellular vessel has the potential to be an off-the-shelf conduit that is resistant to infection and incorporates well into native tissues. This report reviews the rationale of this military-civilian partnership in medical innovation and provides an update on the clinical use and ongoing study of this new vascular technology. LEVEL OF EVIDENCE: Therapeutic, level III.

Forward Surgical Team Experience (FSTE) Is Associated With Increased Confidence With Combat Surgeon Trauma Skills.

Little is known regarding the confidence of military surgeons prior to combat zone deployment. Military surgeons are frequently deployed without peers experienced in combat surgery. We hypothesized that forward surgical team experience (FSTE) increases surgeon confidence with critical skill sets. We conducted a national survey of military affiliated personnel. We used a novel survey instrument that was piloted and validated by experienced military surgeons to collect demographics, education, practice patterns, and confidence parameters for trauma and surgical critical care skills. Skills were defined as crucial operative techniques for hemorrhage control and resuscitation. Surveyors were blinded to participants, and surveys were returned electronically via REDCap database. Data were analyzed with SPSS using appropriate models. Significance was considered p < 0.05. Of 174 distributed surveys, 86 were completed. Nine individuals failed to characterize their FSTE, thus leaving a sample size of 77. At the time of first deployment, 78.4% were alone or with less experienced surgeons and 53.2% had less than 2 yr of post-residency practice. The respondents' confidence in damage control techniques and seven other trauma skills increased relative to FSTE. After adjusting for years of practice, number of trauma resuscitations performed per month and pre-deployment training, there remained a significant positive association between FSTE and confidence in damage control, thoracic surgery, extremity/junctional hemorrhage control, trauma systems administration, adult critical care and airway management. Training programs and years of general surgery practice do not replace FSTE among military surgeons. Pre-deployment training that mimics FST skill sets should be developed to improve military surgeon confidence and outcomes. Prognostic and Epidemiologic, Level IV.

The contemporary timing of trauma deaths.

The distribution of trauma deaths was classically described as trimodal. With advances in both technology and trauma systems, this was reevaluated and found to be bimodal in the early 2000s. Over the last decade there have been continued improvements in trauma and intensive care unit (ICU) care, related to damage control techniques and evidence based ICU pathways. A better understanding of the distribution of trauma deaths may be used to improve trauma systems. This study aimed to evaluate the contemporary distribution of trauma deaths after the widespread implementation of modern trauma and critical care principles. This study included patients entered in the NTDB from 2008 to 2014. For dead patients, hospital length of stay was equated to time until death. Additional data was collected to include demographics, mechanism of injury, Injury Severity Score, and Abbreviated Injury Scale score. Histograms were plotted to demonstrate peaks in deaths. Survival analysis was performed with Kaplan-Meier curves and Gehan-Breslow generalized Wilcoxon tests. 4,185,009 patients were analyzed. Thirty-four percent of all deaths occurred within the first 24 hours of admission. The factors most associated with death in the first 24 hours were severe abdominal trauma (73%), penetrating trauma (55%), and severe extremity trauma (58%). Among patients with penetrating trauma and an abdominal Abbreviated Injury Scale score of 4 or higher, 83% of deaths occurred within 24 hours. When plotted, the distribution of deaths was seen to fall rapidly after the first 24 hours and continued to be flat for 30 days in all subgroups analyzed. In this study, the distribution of trauma deaths no longer appears to be trimodal. This may reflect advances in trauma and ICU care, and the widespread adaption of damage control principles. Early deaths, however, remains a significant challenge, specifically from non-compressible abdominal hemorrhage and extremity trauma. Primary prevention and early hemorrhage control must continue to be a focus of research and trauma systems. Epidemiologic, level IV.

Modified Finney enteroplasty: a bowel sparing damage control stapled technique for penetrating jejunal and ileal injuries.

The rise in gun violence and other penetrating trauma constitutes one of the main challenges in the modern practice of Acute Care Surgery. Expertise in the emergency management of this type of injuries is needed if one is to avoid preventable complications, such as short bowel syndrome. Revisiting and sometimes repurposing old surgical techniques may facilitate this task. The use of a modified Finney enteroplasty as a bowel sparing damage control technique for penetrating jejunal and ileal injuries was studied on 87 gunshot wound victims. The results show this to be a safe and efficient bowel sparing approach to the management of these injuries.

Bowel Anastomosis in Acute Care Surgery

Acute care surgery encompasses the disciplines of trauma, emergency general surgery, and surgical critical care. Inherent in the disease processes of trauma and emergency general surgery is the potential for profound physiologic and anatomic derangements that make the decision to create an intestinal anastomosis, as well as the technique used, a vital step in having a successful outcome for the patient. The trauma literature is rife with conflicting data regarding ideal techniques for anastomosis creation. Two series by Brundage and colleagues suggest that handsewn techniques are superior, which was then contradicted by Witzke et al. Vasopressor usage and blood transfusion appear to put the patient at higher risk for anastomotic failure, as does the utilization of damage control techniques. The emergency general surgery literature is similarly contradicting, with one large retrospective study suggesting handsewn techniques to be superior and a subsequent prospective multicenter study suggesting no difference. Damage control patients do appear to have higher anastomotic failure rates, with the noted absence of good data regarding colorectal resections and ideal management strategies. With the conflicting messages throughout the literature, the acute care surgeon must utilize sound surgical principles and techniques when deciding to perform an anastomosis and choosing a technique to utilize.

A case of successful radical surgical treatment of chronic pancreatitis complicated by a giant pseudoaneurysm of the common hepatic artery

The paper deals with a case report of a female patient with chronic pancreatitis complicated by common hepatic artery pseudoaneurysm, rarely occurred. During the early postoperative period we observed some serious complication that required four operations. The treatment regimen included reconstructive surgical interventions using damage control techniques that allowed achieve positive effect patient.

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.

Thoracic damage control surgery.

The damage control surgery came up with the philosophy of applying essential maneuvers to control bleeding and abdominal contamination in trauma patients who are within the limits of their physiological reserves. This concept was extended to thoracic injuries, where relatively simple maneuvers can shorten operative time of in extremis patients. This article aims to revise the various damage control techniques in thoracic organs that must be known to the surgeon engaged in emergency care. RESUMO A cirurgia de controle de danos surgiu com a filosofia de se aplicar manobras essenciais para controle de sangramento e contaminação abdominal, em doentes traumatizados, nos limites de suas reservas fisiológicas. Este conceito se estendeu para as lesões torácicas, onde manobras relativamente simples, podem abreviar o tempo operatório de doentes in extremis. Este artigo tem como objetivo, revisar as diversas técnicas de controle de dano em órgãos torácicos, que devem ser de conhecimento do cirurgião que atua na emergência.

Outcomes after External Iliac and Femoral Vascular Injuries

Vascular injuries occurring at the junction of the trunk and lower extremity are uncommon yet challenging because of their location and potential for associated truncal injuries. The purpose of this study was to examine and compare outcomes among patients sustaining external iliac and femoral vascular injuries. We performed a 13-year retrospective analysis of our level 1 trauma center database to identify and compare patients with external iliac and femoral vessel injuries. Multiple logistic regression analysis was performed to identify independent predictors for mortality. During the study period, 135 patients with a median (interquartile range [IQR]) age of 25 (20-35) years were identified with external iliac (n=29) and femoral vascular injuries (n=106). The majority were male (85.9%) with a penetrating mechanism (84.5%), and the median (IQR) Injury Severity Score (ISS) was 16 (11-26). The overall mortality rate was 14.1%. In comparison with patients with femoral vascular injuries, patients with external iliac injuries presented with higher ISS (25 vs. 16, P<0.001), lower Glasgow Coma Scale (14 vs. 15, P=0.001) and had a higher incidence of mortality (41.4% vs. 6.6%, P<0.001) and disability (13.8% vs. 1%, P=0.007). Shunts were used in only 7 patients (5.2%). Stepwise logistic regression consistently identified external iliac injury (odds ratio, 15.6; 95% confidence interval, 1.72-141, P=0.014 in best-fitted model) as independently associated with mortality. In comparison with femoral vascular injuries, external iliac vascular injuries are associated with higher blood loss, more intense resuscitation, higher disability and mortality in patients sustaining junctional groin injuries. Early recognition and application of damage control techniques and resuscitative practices may result in improved outcomes.

Damage Control Vascular Surgery in the Austere Environment

Managing vascular trauma in an austere environment with limited resources will challenge even the most seasoned surgeon. Successful management requires immediate hemorrhage control, and then, the surgeon must make critical decisions for limb salvage to be successful. This chapter highlights the principles of vascular management and provides damage control techniques that can be applied in a wide array of trauma settings.

Acute Care/Trauma Surgeon's role in obstetrical/gynecologic emergencies (The OBCAT Alert).

Overwhelming hemorrhage or other intra-abdominal complications may be associated with obstetrical or gynecologic (OB/GYN) procedures and may require the surgical training of an Acute Care/Trauma Surgeon. The OB Critical Assessment Team (OBCAT Alert) was developed at our institution to facilitate a multidisciplinary response to complex OB/GYN cases. We sought to review and characterize the Acute Care/Trauma Surgeon's role in these cases. We conducted a retrospective review of all emergency consults during an OB/GYN case at our institution from 2008 to 2015. An OBCAT is a hospital based alert system designed to immediately notify OB/GYN, anesthesiology, Acute Care/Trauma, the intensive care unit (ICU), and the blood bank of a potential emergency during an OB/GYN case. There were 7±3 OBCAT alerts/year. Seventeen patients required Acute Care/Trauma surgery intervention for hemorrhage. Thirteen patients required damage control packing during their hospitalization. Blood loss averaged 6.8±5.5 L and patients received a total of 21±14 units during deliveries with hemorrhage. There were 17 other surgical interventions not related to hemorrhage; seven of these cases were related to adhesions or intestinal injury. Seven additional cases required evaluation post routine OB/GYN procedure; the most common reason was for severe wound complications. There were three deaths during this study period. Emergency OB/GYN cases are associated with high morbidity and may require damage control or other surgical techniques in cases of overwhelming hemorrhage. Acute Care/Trauma Surgeons have a key role in the treatment of these complex cases.

Management of Critical Bleeding in Trauma Patients: Between Recommendations and Reality

Uncontrollable haemorrhage is the most frequent cause of early death in trauma patients. Massive haemorrhage may be exacerbated by coagulopathy early after trauma, and may transit to critical bleeding that does not respond to surgical haemostasis. The treatment strategies should focus on achieving haemostasis as soon as possible and correcting coagulopathy; otherwise efforts at resuscitation are likely to be useless. Rapid control of the source of bleeding with damage control techniques instead of complete repair, interventional radiology especially in abdominal-pelvic trauma, use of blood derived products and haemostatic agents are essential. Rotational thrombelastometry is used to promptly assess coagulation, but when it is not available, routine laboratory-based coagulation tests may be used for assessment of fibrinolysis. Early coagulation support may prevent acquired coagulopathy. The recommendations to avoid critical bleeding are constantly updated but in many situations, due to limited resources they cannot be applied completely. Recognizing the predictors of mortality with early monitoring of prothrombin time, activated partial thromboplastin time, fibrinogen and platelets, target haemostatic therapy with lysine derivates and substituted coagulation factors in order to avoid packed red blood cells and fresh frozen plasma, are of vital importance. Protocol for the treatment of patient with major bleeding will depend on rational strategy which relies on the resources available. Tranexemic acid should be given in massive bleeding, even in the absence of clinically diagnosed hyperfibrinolysis. Fibrinogen and platelets have to be administered in order to provide thrombin formation when hyperfibrinolysis is considered. Bleeding that continues despite fibrin supplementation and adequate number of platelets may be a result of insufficient thrombin formation; in this case prothrombin complex concentrates may be the first line therapy for thrombin deficiency. Strategy in treatment of trauma patients relies on resource availability

Damage control surgery.

Damage control surgery (DCS) has become a lifesaving maneuver for critically injured patients when utilized in appropriate scenarios. Despite this reality, indications for initiating DCS remain debated. Despite discussion surrounding the appropriate indications for DCS, this series of fundamental principles includes a rapidly abbreviated operative intervention aimed at arresting ongoing hemorrhage and containing gastrointestinal contamination in a patient approaching physiologic exhaustion, which includes both vascular and nonvascular damage control techniques, in addition to management of the open abdomen. Patients are then returned to the operating theater for definitive reconstruction once their physiology has been stabilized within the ICU. DCS is lifesaving when applied in appropriate clinical scenarios involving critically injured patients. Overuse of this technique can lead to increased patient morbidity and cost however.

Temporary vascular shunt for damage control of extremity vascular injury: A toolbox for trauma surgeons

In an emergency, a general surgeon may be faced with the need to treat arterial trauma of the extremities when specialized vascular surgery is not available in their hospital setting, either because an arterial lesion was not diagnosed during pre-admission triage, or because of iatrogenic arterial injury. The need for urgent control of hemorrhage and limb ischemia may contra-indicate immediate transfer to a hospital with a specialized vascular surgery service. For a non-specialized surgeon, hemostasis and revascularization rely largely on damage control techniques and the use of temporary vascular shunts (TVS). Insertion of a TVS is indicated for vascular injuries involving the proximal portion of extremity vessels, while hemorrhage from distal arterial injuries can be treated with simple arterial ligature. Proximal and distal control of the injured vessel must be obtained, followed by proximal and distal Fogarty catheter thrombectomy and lavage with heparinized saline. The diameter of the TVS should be closely approximated to that of the artery; use of an oversized TVS may result in intimal tears. Systematic performance of decompressive fasciotomy is recommended in order to prevent compartment syndrome. In the immediate postoperative period, the need for systematic use of anticoagulant or anti-aggregant medications has not been demonstrated. The patient should be transferred to a specialized center for vascular surgery as soon as possible. The interval before definitive revascularization depends on the overall condition of the patient. The long-term limb conservation results after placement of a TVS are identical to those obtained when initial revascularization is performed.

Operative Management of Lung Injuries

The need for operative management of pulmonary injury is uncommon. However, delaying patients requiring a thoracotomy for trauma increases morbidity and mortality; thus, the key aspect in management in this patient population is timely an operative intervention. Once the decision is made to perform a thoracotomy, the goal is to obtain control of hemorrhage as soon as possible. Lung lacerations from penetrating trauma usually have a tract though the pulmonary parenchyma and are usually amenable to lung-sparing techniques such as tractotomy or limited resections. Injuries from blunt trauma usually result in more significant tearing of the lung and are more likely to require larger resections. With modern approach to resuscitation, it is more important to quickly control hemorrhage than to worry about removing “too much lung.” Damage control techniques including temporary hilar clamping and chest packing are useful adjuncts to achieve survivorship in those patients with extensive chest trauma.

The role of the open abdomen procedure in managing severe abdominal sepsis: WSES position paper.

The open abdomen (OA) procedure is a significant surgical advance, as part of damage control techniques in severe abdominal trauma. Its application can be adapted to the advantage of patients with severe abdominal sepsis, however its precise role in these patients is still not clear.In severe abdominal sepsis the OA may allow early identification and draining of any residual infection, control any persistent source of infection, and remove more effectively infected or cytokine-loaded peritoneal fluid, preventing abdominal compartment syndrome and deferring definitive intervention and anastomosis until the patient is appropriately resuscitated and hemodynamically stable and thus better able to heal.However, the OA may require multiple returns to the operating room and may be associated with significant complications, including enteroatmospheric fistulas, loss of abdominal wall domain and large hernias.Surgeons should be aware of the pathophysiology of severe intra-abdominal sepsis and always keep in mind the option of using open abdomen to be able to use it in the right patient at the right time.

Cryoamputation: An old surgical technique to be kept on ice?

Cryoamputation is a little known method of delaying a surgical amputation by rapid freezing of the affected limb to prevent further derangement of systemic physiology – hence its historical name of ‘physiologic amputation’. Rapid cryoamputation allows for a period of optimisation before surgical amputation in unstable patients. There is limited published literature on the technique and a systematic review was undertaken to identify the techniques, potential indications, complications and potential relevance to current practice and related novel developments. A literature review produced 15 relevant papers that were reviewed; all were either case reports or case series. Cryoamputation can be a lifesaving procedure in a cohort of patients at a high risk of mortality. It is a historical damage control technique and whilst it is unlikely to be used regularly, it is an effective, rapid and simple technique that should not yet be forgotten.