Damage Control Principles Research Articles

The European Perspective on the Management of Acute Major Hemorrhage and Coagulopathy after Trauma: Summary of the 2019 Updated European Guideline.

Non-controlled hemorrhage with accompanying trauma-induced coagulopathy (TIC) remains the most common cause of preventable death after multiple injury. Rapid identification followed by aggressive treatment is the key for improved outcomes. Treatment of trauma hemorrhage begins at the scene, with manual compression, the use of tourniquets and (non) commercial pelvic slings, and rapid transfer to an adequate trauma center. Upon hospital admission, coagulation monitoring and support are to be initiated immediately. Bleeding is controlled surgically following damage control principles. Modern coagulation management includes goal-oriented, individualized therapies, guided by point-of-care viscoelastic assays. Idarucizumab can be used as an antidote to the thrombin inhibitor dabigatran, andexanet alpha as an antidote to factor Xa inhibitors. This review summarizes the key recommendations of the 2019 updated European guideline on the management of major bleeding and coagulopathy following trauma. These evidence-based recommendations may form the backbone of algorithms adapted to local logistics and infrastructure.

Application of the damage control principles and the use of a local negative pressure system for the prevention of infectious complications in a patient with traumatic separation of the upper limb and massive damage to soft tissues

The article presents a clinical case of the successful treatment of a patient with traumatic separation of the upper limb and massive damage to the soft tissues of the upper shoulder and chest. The effectiveness of applying the damage control principles and the method of local negative pressure for the prevention of local and systemic infectious complications is emphasized.

Terrorist attacks: common injuries and initial surgical management.

Terrorism-related incidents and shootings that involve the use of war weapons and explosives are associated with gunshot and blast injuries. Despite the perceived threat of terrorism, these incidents and injuries are rare in Germany. For this reason, healthcare providers are unlikely to have a full understanding of the special aspects of managing these types of injuries. Until a clear and complete picture of the situation is available after a terrorist or shooter incident, tactical and strategic approaches to the clinical management of the injured must be tailored to circumstances that have the potential to overwhelm resources temporarily. Hospitals providing initial care must be aware that the first patients who are taken to medical facilities will present with uncontrollable bleeding from injuries to the trunk and body cavities. To improve the outcome of these patients in extremis, the aim of the index surgery is to stop the bleeding and control the contamination. Unlike damage control surgery, which is tailored to the patient's condition, tactical abbreviated surgical care (TASC) is first and foremost adapted to the overall situation. Once the patients are stabilised and all information on the situation is available, the surgical management and reconstruction of gunshot and blast injuries can follow the principles of damage control (DC) and definitive early total care (ETC). The purpose of this article is to provide an overview of the pathophysiology of gunshot and blast injuries, wound ballistics, and the approach and procedures of successful surgical management.

An integrated strategy of TCM and western medicine to prevent and treat acute abdomen during the outbreak of COVID-19

At present, the prevention and control of the COVID-19 is still severe, its pathogen SARS-CoV-2 is highly infectious and pathogenic, and the population is generally susceptible. Thus, it requires a higher standard to diagnose and treat patients with acute abdomen. The first step is to carry out procedures to identify whether the patient is infected or not. Those who are not infected can go through the normal treating procedures. For patients diagnosed with COVID-19 or suspected patients, the second step is to achieve classified diagnoses and treatments, and to adopt a treating plan that integrates TCM and western medicine. In order to protect patients and medical staff, the COVID-19 in hospital transmission must be avoided. For patients with COVID-19 who need emergency surgery, we must strictly comply with the hospital's protection regulations, closely coordinate the relevant departments of surgery, perform the three-level protection, operate in accordance with the principle of damage control in the negative pressure surgery room, and return to the isolation ward according to the prevention and control process after operation. For units without surgical conditions, patients should be transferred to hospital in time on the premise of maximum damage control, and patients must not be delayed for timely diagnosis and treatment due to the epidemic. Key words: Novel coronavirus; Pneumonia, viral; Acute abdominal diseases; Traditional Chinese and Western Medicine

Prevention and treatment strategies of Traditional Chinese and Western Medicine for acute abdomen during the outbreak of COVID-19

At present, the prevention and control of the COVID-19 is still severe, its pathogen SARS-CoV-2 is highly infectious and pathogenic, and the population is generally susceptible. In order to deal with the epidemic, selective operation can be postponed, but most of the patients with acute abdominal diseases are commonly in clinic, with acute onset and severe condition, and most of them are accompanied with fever and gastrointestinal symptoms, so emergency operation is needed.Under the condition of the current epidemic—COVID-19, it requires a higher standard to diagnose and treat patients with acute abdomen. The first step is to carry out procedures to identify whether the patient is infected or not. Those who are not infected can go through the normal treating procedures.For patients diagnosed with COVID-19 or suspected patients, the second step is to achieve classified diagnoses and treatments, and to adopt a treating plan that integrates TCM and western medicine.In order to protect patients and medical staff, the COVID-19 in hospital transmission must be avoided. For patients with COVID-19 who need emergency surgery, we must strictly comply with the hospital's protection regulations, closely coordinate the relevant departments of surgery, perform the three-level protection, operate in accordance with the principle of damage control in the negative pressure surgery room, and return to the isolation ward according to the prevention and control process after operation. For units without surgical conditions, patients should be transferred to hospital in time on the premise of maximum damage control, and patients must not be delayed for timely diagnosis and treatment due to the epidemic. Key words: novel coronavirus; pneumonia; viral; acute abdominal diseases; Traditional Chinese and Western Medicine

Application of Damage Control Neurosurgery and Corresponding Nursing Strategy in Patients with Bilateral Frontal Lobe Contusion and Laceration

Objective: To investigate the key points and effect of damage control neurosurgery (DCNS) and nursing strategy of patients with neurosurgery in bilateral frontal contusion. Methods: According to the principle of damage control nursing strategy of neurosurgery, 33 cases of bilateral frontal contusion from September 2017 to January 2019 were treated by adjusting the internal environment disorder after trauma, increasing plasma osmotic pressure and maintaining blood oxygen saturation, craniotomy and decompression operations when patients grew worse. Patients were followed up for 6 months with the corresponding nursing practice given to the patients out of hospital. Results: Among the 33 cases, 25 of them received successful conservative treatment, 8 were converted to surgery. The operation rate was 24.2%. Six months after treatment, there were 27 cases with GOS ≥ 4, including 22 cases GOS ≥ 4 in the conservative treatment group and 5 cases GOS ≥ 4 in the surgery transfer group. Conclusion: The application of DCNS in the treatment of bilateral frontal contusion and take appropriate nursing strategy intervention can reduce the operation rate, prevent complications and promote patient’s recovery.

Results of Conversion Osteosynthesis in Treatment of Patients with Long Bone Fractures

Аbctract. Treatment of long bones fractures of the extremities has a particular relevance in modern traumatology due to their high frequency, as well as a large number of deaths in patients with polytrauma. It is dangerous to perform an urgent final osteosynthesis in severe patients because of the possibility of shock and the deterioration of the condition of the injured. Therefore, the principle of Damage control with urgent fixation of damaged segments by external fixation and their subsequent replacement (converse) to intramedullary osteosynthesis had a particular relevance in the treatment of patients with long bones fractures. Purpose: Improving treatment outcomes for patients with long bones fractures. Materials and methods. In the present study, a retrospective analysis of using conversion osteosynthesis in the treatment of 120 patients with long bones extremities fractures in a multidisciplinary hospital was carried out. For a better analysis of the results of treatment, we divided the patients into two groups: The first group 44 patients with fractures of the long bones with polytrauma according to the ISS severity scale> 17. The second group consists of 76 patients with closed isolated unstable comminuted fractures of the long bones with severe post-traumatic edema, who have a high risk of significant trauma of soft tissues. Results. The most optimal time for conversion osteosynthesis to patients with polytrauma was 7-12 days, which prevented the occurrence of traumatic shock; and for patients with closed isolated unstable fractures of long bones with significant of post-traumatic edema for conversion osteosynthesis, the optimal time was 3-7 days after injury, which prevented the occurrence of inflammatory complications in the postoperative period. Conclusion. The study confirmed the feasibility of conversion osteosynthesis in the treatment of patients with diaphyseal fractures. The use of the technique of transferring the fixation of fragments by the external fixation device to the internal osteosynthesis (conversion) contributed to a reduction in the duration of inpatient treatment of patients with fractures of the long bones.

The Diagnosis and Treatment of Acute Traumatic Bleeding and Coagulopathy.

Uncontrolled bleeding with trauma-induced coagulopathy (TIC) is still the most common avoidable cause of death in multiple trauma. The aging of the population has led to an increasing number of bleeding trauma patients with pre-existing anticoagulation. Such patients are not treated uniformly, even in major trauma centers. This review is based on a selective search of the literature (Medline/PubMed, Cochrane Reviews) and summarizes current treatment recommendations, including those of the newly revised European trauma guidelines. The treatment of traumatic hemorrhage begins at the site of the accident, with compression, tourniquets, pelvic binders, and rapid transport to a certified trauma center. The early use of tourniquets was shown to lessen the trans- fusion requirement (packed red blood cells: 2.0 ± 0.1 vs. 9.3 ± 0.6; p < 0.001; fresh frozen plasma concentrates: 1.4 ± 0.08 vs. 6.2 ± 0.4; p < 0.001), while external pelvic stabilization was shown to reduce mortality (19.1% vs. 33.3%). Upon the patient's arrival in the hospital, steps are taken to measure, monitor, and support clotting function. Bleeding is controlled surgically according to the principles of damage control. Modern clotting management consists of goal-oriented, individualized therapy, including the use of point-of-care viscoelastic test procedures. Idarucizumab can be used as an antidote to the thrombin inhibitor dabigatran, andexanet alpha as an antidote to factor Xa inhibitors. The evidence-based treatment of patients with hemorrhage from severe trauma, in accordance with the existing guidelines, can improve the clinical outcome. Corresponding algorithms, adapted to local logistics and infrastructure, must be developed and implemented.

Surgical tactics of treatment of the wounded persons with the gun-shot injuries of the hip on all levels of medical support

Objective. To substantiate the introduction of differentiated surgical tactics, taking into account the trauma severity for improvement of the treatment results in the wounded persons, suffering the gun-shot injuries of the hip (GSIH).&#x0D; Маterials and methods. Differentiated surgical tactics was substantiated by the authors, using as a measure for trauma severity estimation the AdTS (Admission trauma Scare) on different levels of medical support, and introduced in 57 wounded persons, suffering the GSIH. Medical efficacy of the tactics and treatment elaborated for the wounded persons was compared in accordance to conventional methods without application of the AdTS scale.&#x0D; Results. There was reduced the mortality from 7.3 tо 1.8%, the extremities amputation performance rate - from 24.4 tо 8.8%, the local complications quantity, calculated for one wounded person, - from 1.07 tо 0.58 (рα &lt; 0.05), relative quantity of poor functional results - from 34.1 tо 19.3% (рα &lt; 0.05), while the specific weight of good functional results increased - from 29.3 to 47.4 due to introduction of differentiated surgical tactics, taking into account the trauma severity on various levels of medical support.&#x0D; Conclusions. In the wounded persons, suffering nonsevere trauma (lesser, than 5 points) it is necessary to perform a complete volume of surgical aid; while in severe one (5 - 9 points) and in extremely high (more than 9 points) trauma the help must be delivered in a shortened volume, using the damage control principle.

3D-printed template-assisted reduction of long bone fractures

In multiply injured patients, the time period between the initial treatment with external fixators (damage control) and the definitive treatment can last from days to weeks. Apoor reduction result with the fixator (e.g. malposition in axis, length and rotation) and along delay from trauma to definitive osteosynthesis are associated with longer operation times, higher intraoperative radiation doses, higher infection rates and an increased likelihood for the necessity to perform an open reduction. In the described technique computed tomography (CT) is performed after temporary stabilization of the long bone fracture by an external fixator. On the basis of athree-dimensional dataset the fracture can be virtually reduced and apatient-specific reduction fixator can be designed and printed. The 3Dprinted reduction fixator fits only in the reduced position of the fracture, thus maintaining anatomical bone alignment. The procedure was used for the first time in the Trauma Surgery Clinic of the Medical University Hanover in May 2018 in a polytraumatized female patient with severe brain injury and an open floating knee injury. The procedure could be performed for femoral and tibial shaft fractures. The postoperative CT showed asatisfactory reconstruction of length, torsion and frontal and sagittal plane alignment. Fracture healing was uneventful within 3 months. Severely injured patients who initially receive stabilization according to the damage control principle and subsequently remain in the intensive care unit, could particularly benefit from the described postoperative reduction technique. In addition, the reduction fixator can be helpful for the definitive treatment of patients with bilateral fractures of long bones, where a reference to a healthy side is not possible.

Development of a Field-Expedient Vascular Trauma Simulator.

The past few years have noted significant declines in combat casualty exposure over the course of a deployment. As a result, overall confidence and comfort in performing potentially life-saving therapies may wane during a deployment. Development of training simulators provides a method for bridging this gap. Herein, a field-expedient vascular trauma trainer for noncompressible torso hemorrhage is described. A low-fidelity simulator was created using a Penrose drain, intravenous tubing, suture, and a cardboard box. A higher-fidelity simulator was created using an aortobifemoral bypass graft, double-lumen endotracheal tube, suture, and an upper torso mannequin. The two trainers were successfully used to train for peripheral shunt placement and definitive vascular repair. The trainer makes use of supplies readily found at most Role 2 and 3 facilities and that are obtainable for Role 1 facilities providing damage control surgery. It provides a just-in-time way to develop and sustain confidence in the damage control principles applicable to vascular injuries.

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.

Fluid therapy in trauma resuscitation : A review of changing practices.

Background: Haemorrhage is the leading preventable cause of post trauma death. Acute trauma resuscitation has evolved over the last decade. The ATLS guidance used since 2012 is being updated in 2018.Objectives : To search relevant representative literature over 6 years between 2012 and 2018 to gain an insight into changing concepts, practices and recent advances in acute trauma fluid resuscitation and provide a structured review of the topic.Search methods: A relevant MEDLINE search was undertaken to obtain a list of 1512 articles from which 107 were utilised to prepare this review.Selection criteria:1. Inclusion: Articles from human medicine relevant to fluid resuscitation in trauma published in English between January 2012 and January 2018. 2.Exclusion: Articles restricted to Brain, spinal trauma or cardiovascular trauma, post traumatic arrest patients, animal or human laboratory model studies and articles on septic, postoperative, obstetric patients and single case studies were excluded.Results: This review categorises the topic into various parts to explain the evolving understanding of fluid resuscitation, trauma induced coagulopathy and endotheliopathy of trauma. The strategies for acute fluid management like damage-controlled resuscitation, balanced and haemostatic resuscitation and massive transfusion protocol are explained. A detailed discussion is carried out regarding crystalloid, colloid and blood transfusion. Special consideration is given to specific age groups, combat casualties and prehospital trauma care.Conclusions: Fluid resuscitation in trauma is a complex and rapidly evolving subject. Massive transfusion protocols and principles of damage control are significant for patient outcome. Standard guidance like ATLS is relevant and important for training professionals to deliver systematic, high quality of trauma care. There is scope for local improvisation based on resources and need for more high-quality trials and frequent systematic reviews.Bangladesh Crit Care J March 2018; 6(1): 31-39

Terrorist attack in Nice – The experience of general surgeons

After the attacks in Paris, France was again struck by terrorism in the city of Nice during the night of July 14, 2016. At 22:33 in the evening, a 19-ton truck drove into the crowd of holiday celebrators. The attack resulted in 458 wounded and 86 deaths. The purpose of this study was to describe the management of patients with abdominal trauma admitted alive in our institution, in the context of a massive influx of victims. We performed a retrospective analysis of the management of adults with abdominal trauma arising from the terrorist attack in Nice. Among the 182 victims admitted to our trauma center, eleven patients presented with abdominal trauma. The median age was 44 years [14-63] and the median Injury Severity Score (ISS) was 34 [9-59]. Eight patients underwent urgent surgical treatment in the operating room including six for abdominal trauma. These patients were treated according to the principles of surgical damage control, albeit without the need for temporary abdominal closure or packing. Three patients could have had their lesions managed non-operatively had they been admitted outside this surge episode, which saturated the technical means of the receiving hospital. The terrorist attack that victimized the citizens of Nice resulted in the second largest number of dead of any attack on French soil. A large number of patients were admitted to the city's only center for adult trauma care. The management of these patients posed diagnostic, therapeutic and logistical problems. Increased use of pre-hospital pelvic restraint belts may help to reduce vehicular trauma. We do not feel that non-operative management of abdominal lesions can be envisaged in the context of a mass influx of victims. We recommend surgical hemostasis for patients with secondary hemorrhagic risk from visceral trauma in the context of a massive influx of victims.

Urgency surgical treatment for ruptured hepatic adenoma: experience of 23 years

Background: Hepatocellular adenoma (HA) is a benign tumor, which mainly affects young women using oral contraceptives, usually presenting as a single nodule. The clinical picture varies from abdominal pain in the epigastrium and right hypochondrium with palpable mass to asymptomatic or by one of its complications, such as malignancy or rupture. When ruptured, it may present with acute abdominal pain, which may lead to intrahepatic or intraperitoneal bleeding with or without signs of hypovolemic shock. If the patient remains hemodynamically unstable despite adequate volume resuscitation, immediate surgical intervention is necessary, recommending principles of damage control of hepatic trauma, aiming at adequate hemostasis, hepatectomy in this situation is a procedure associated with considerable morbidity and mortality. Methods: Analyze the epidemiology, risk factors and surgical treatment of HA with rupture (RHA) in University of Campinas in a last 22 years. The records of the patients with confirmed pathology of RHA submitted to surgery on University of Campinas from 1995 to 2017 were retrospectively evaluated. The diagnosis of HA was confirmed by the histology being categorized by the presence or absence of Rupture by clinical signs or radiological findings. Results: There were 28 cases of HA submitted to surgery, of which 8 RHA (28.57%), the mean age was 35.05 years, 7 were female and 1 male. Five of these patients used oral contraceptives. Mean intraoperative bleeding was 3084.5 ml, with 3 deaths occurring. Conclusion: RHA may or may not be associated with hemodynamic instability, a potentially life threatening condition, mainly associated with lesion size and OAC use. In centers where interventional radiology is not available surgical treatment is indicated to control bleeding and stabilize the patient with high morbidity and mortality.

Management specificities for abdominal, pelvic and vascular penetrating trauma

Management of patients with penetrating trauma of the abdomen, pelvis and their surrounding compartments as well as vascular injuries depends on the patient's hemodynamic status. Multiple associated lesions are the rule. Their severity is directly correlated with initial bleeding, the risk of secondary sepsis, and lastly to sequelae. In patients who are hemodynamically unstable, the goal of management is to rapidly obtain hemostasis. This mandates initial laparotomy for abdominal wounds, extra-peritoneal packing (EPP) and resuscitative endovascular balloon occlusion of the aorta (REBOA) in the emergency room for pelvic wounds, insertion of temporary vascular shunts (TVS) for proximal limb injuries, ligation for distal vascular injuries, and control of exteriorized extremity bleeding with a tourniquet, compressive or hemostatic dressings for bleeding at the junction or borderline between two compartments, as appropriate. Once hemodynamic stability is achieved, preoperative imaging allow more precise diagnosis, particularly for retroperitoneal or thoraco-abdominal injuries that are difficult to explore surgically. The surgical incisions need to be large, in principle, and enlarged as needed, allowing application of damage control principles.

Evaluation and Management of Non-iatrogenic Ureteral Trauma

Ureteral injuries are rare and represent a minority of genitourinary injuries in trauma patients. Their association with complex polytrauma and propensity for delayed recognition present diagnostic and therapeutic challenges. Herein, we present a review of the available literature on the evaluation and management of non-iatrogenic ureteral injuries. The incidence of traumatic ureteral injury appears to be increasing as a result of improved trauma survivability and enhanced imaging techniques. While most of the ureteral trauma literature reports on penetrating mechanisms of injury, blunt ureteral injuries are typically associated with more severe injury scores. Diagnosing traumatic ureteral injuries continues to be challenging and clinical suspicion should guide subsequent evaluation based on the patient’s condition. Computerized tomography with intravenous contrast and excretory phase imaging is the gold standard for evaluating suspected ureteral injuries in clinically stable trauma patients. Many ureteral injuries will still be diagnosed intraoperatively and may be successfully temporized or definitively reconstructed acutely. In unstable patients, damage control principles have been adapted to ureteral trauma permitting delayed reconstruction. Delayed diagnosis of these injuries has been associated with increased morbidity, mortality, length of stay, and renal loss. Traumatic ureteral injuries are rare and require a high index of suspicion. Patient physiology may guide the evaluation and eventual treatment of these injuries. Improved detection, management, and vigilance for potential complications of traumatic ureteral injuries can improve patient outcomes and decreased resource utilization.

Surgical support during the terrorist attacks in Paris, November 13, 2015: Experience at Bégin Military Teaching Hospital.

Recent conflicts have allowed the French Army Health Service to improve management quality for wartime-injured people during military operations. On November 13, 2015, it was in Paris that France was directly attacked and Bégin Military Teaching Hospital, like several hospitals in Paris, had to face a large number of gunshot victims. Thanks to our operational experience, injured people hospitalized in military hospitals benefited from a management based on triage and damage control (DC) principles. Forty-five patients were taken care of in our hospital with an average age of 32 years. During triage, eight patients were categorized T1 (with four extreme emergencies) and 10 were classified T2 and 27 as T3. Twenty-two patients underwent emergency surgery, 15 for soft tissue lesions of limbs, 8 for ballistic fractures (one of which was a cervical wound), and 5 for abdominal wounds. Two patients classified T1 died early. In total, more than 50 operations were performed including iterative debridements, bone fixation, three amputations, and two flaps. After 9 months, all of the patients had healed. One woman with limb stiffness required an arthrolysis. This event showed that terrorist attacks and mass casualties with war wounds can occur in France. Acquired experience regarding war wounds by the French Army Health Service is precious. Everyone must understand the importance of triage and the principles of damage control. Every hospital must be ready to face this type of massive influx of injured people (white plan). Epidemiological study, level V.

Caring for critically injured children: An analysis of 56 pediatric damage control laparotomies.

Injury is the leading cause of death in children under 18 years. Damage control principles have been extensively studied in adults but remain relatively unstudied in children. Our primary study objective was to evaluate the use of damage control laparotomy (DCL) in critically injured children. An American College of Surgeons-verified Level 1 trauma center review (1996-2013) of pediatric trauma laparotomies was undertaken. Exclusion criteria included: age older than 18 years, laparotomy for abdominal compartment syndrome or delayed longer than 2 hours after admission. Demographics, mechanism, resuscitation variables, injuries, need for DCL, and outcomes were evaluated. Independent t test, Mann-Whitney U test, Fisher's exact test, and single-factor analysis of variance assessed statistical significance. Study endpoints were hospital survival and DCL complications. Of 371 children who underwent trauma laparotomy, the median age (IQR; LQ-UQ) age was 16 (5; 11-17) years. Most (73%) were male injured by blunt mechanism (65%). Fifty-six (15%) children (Injury Severity Score [ISS], 33 (25; 17-42), pediatric trauma score 5 (6; 2-8), penetrating abdominal trauma index score [PATI] 29 (32; 12-44)) underwent DCL after major solid organ (63%), vascular (36%), thoracic (38%) and pelvic (36%) injury. DCL patients were older (16.5 (4; 14-18) vs. 16 (7; 10-17)) and were more severely injured (ISS, 33 [25; 17-42] vs. 16 [16; 9-25]), requiring greater intraoperative packed red blood cell transfusion (8 [13; 3.5-16.5] vs. 1 (0; [0-1] units) than definitive laparotomy counterparts. Nonsurvivors arrived in severe physiologic compromise (base deficit, 17 [17; 8-25] vs. 7 [4; 4-8]), requiring more frequent preoperative blood product transfusion (67% vs. 10%) after comparable injury (ISS survivors, 36 [23; 18-41] vs. nonsurvivors 26 (7; 25-32), p = 0.8880). Fifty-five percent of DCL patients survived (length of stay, 26 [21; 18-39] days) requiring 3 (2; 2-4) laparotomies during 4 (6; 2-8) days until closure (fascial, 90%; vicryl/split thickness skin grafting, 10%). DCL complications (surgical site infection, 18%; dehiscence, 2%; enterocutaneous fistula, 2%) were analyzed. When stratified by age (<15 years vs. 15-18 years) and period (1996-2006 vs. 2007-2013), no differences were found in injury severity or DCL outcomes (p > 0.05). After controlling for DCL, age, and gender, multivariate analysis indicated only ISS (odds ratio, 1.10 [95% confidence interval, 1.01 - 1.19], p = 0.0218) and arrival systolic blood pressure (odds ratio, 0.96 [95% confidence interval, 0.93-0.99], p = 0.0254) predicted mortality after severe injury. DCL is a proven, lifesaving surgical technique in adults. This report is the first to analyze the use of DCL in children with critical abdominal injuries. With similar survival and morbidity rates as critically injured adults, DCL merits careful consideration in children with critical abdominal injuries. Therapeutic study, level IV.

Management of colorectal trauma: a review.

Traumatic colorectal injuries are common during times of military conflict, and major improvements in their care have arisen in such periods. Since World War II, many classification systems for colorectal trauma have been proposed, including (i) Flint Grading System; (ii) Penetrating Abdominal Trauma Index; (iii) Colonic/Rectal Injury Scale; and (iv) destructive/non-destructive colonic injuries. The primary goal of these classifications was to aid surgical management and, more particularly, to determine whether a primary repair or faecal diversion should be performed. Primary repair is now the preferred surgical option. Patients who have been identified as having destructive injuries have been found to have higher anastomotic leak rates after a primary repair. Damage control principles need to be adhered to in surgical decision-making. In this review, we discuss the mechanisms of injury, classifications, clinical presentation and current recommendations for the management of colorectal trauma.