Require Damage Control Surgery Research Articles

Surgical Techniques for Severe Liver Injury: A Comprehensive Review of Current Approaches and Advancements

In abdominal trauma, the liver is the most injured organ and treatment is usually determined by hemodynamics. Severe liver injury with extensive parenchymal injury and uncontrollable bleeding may rapidly evolve into the lethal triad of death (acidosis, hypothermia, and coagulopathy), requiring damage control surgery (DCS). Damage control resuscitation for trauma treatment reduces the need for DCS by enabling rapid control of massive bleeding. Thus, definitive surgery can be completed in one operation. Despite the systematic application of damage control resuscitation, definitive surgery cannot be achieved in severe, and extensive liver injuries. Therefore, understanding, and acquiring damage control surgical techniques is necessary to achieve DCS for severe liver injury. The Western Trauma Association and the World Society of Emergency Surgery have proposed algorithms for the nonoperative and operative management of blunt hepatic trauma. The algorithms list several surgical skills, including electrocautery or argon beam, manual compression, perihepatic packing, the Pringle maneuver, liver suture, omental packing, selective hepatic artery ligation, balloon tamponade, hepatic vascular isolation, and the shunt operation. These techniques require a multidisciplinary approach and individual honing of skills by the surgeon. Trauma surgeons, even hepatobiliary surgeons, must practice damage control techniques in severe liver injury models (animals or cadavers).

FTP1.11 Retroperitoneal injury is associated with anastomotic leak after colonic injury

Abstract Background The aim of this retrospective observational study was to investigate the association between concomitant retroperitoneal injury and colonic repair failure. Operative repair of perforating colonic injury should ideally maintain bowel continuity. Diversion may be preferable where the repair is likely to fail. To make this decision surgeons must be aware of factors associated with risk of operative failure. Concomitant retroperitoneal injury (RPI) may represent an occult risk factor for post-operative colonic complications. Methods Single-centre study of adult patients admitted to a Level 1 trauma centre between June 2015 and July 2020. Trauma patients with full thickness perforation of either the colon or intraperitoneal rectum were included. We compared clinical outcomes and specifically the incidence of colonic repair leak in patients with or without retroperitoneal injury (RPI). Results Seventy-seven patients met inclusion criteria, of whom 33/77 (43%) had RPI. Mechanism of injury was penetrating in 61/77 (79%) and 49/77 (64%) had isolated abdominal injuries. Patients with RPI had significantly more leaks compared to patients without (9/33 [27%] versus 3/44 [7%], RR 2.0, 95%CI 1.2 to 3.1 p=0.024). Post-operative leak was higher in shocked patients (shock 3/11 [27%] versus not-shocked 9/65 [14%], p=0.37) or those requiring damage control surgery (DCS) (DCS 6/23 [26%] versus non-DCS 6/54 [11%], p=0.17) but neither reached statistical significance. Conclusions RPI is associated with an increased incidence of complications after colonic repair. When selecting operative strategy for perforating colonic injury, surgeons should be aware of increased risk of operative failure in the presence of concomitant RPI.

Evaluation of resuscitation with angiography, percutaneous techniques and operative repair (RAPTOR): hybrid suite introduction and initial use at a level I urban trauma centre.

The aim of this study was to describe the utilization of the RAPTOR suite (hybrid theatre) for trauma patients. Ideally, this is used to achieve haemorrhage control in time-critical patients that may require damage control surgery (DCS) and/or interventional radiological (IR) procedures concurrently. A single-centre, retrospective study identifying all trauma patients that were treated at the level I trauma centre during 2011-2016 was performed. Patients that underwent treatment in the RAPTOR suite were described. Subgroup analyses were performed for trauma patients that underwent interventions within 60min and patients who underwent a combination of DCS + angioembolization in the RAPTOR suite or in other locations (OR, radiology). Since its introduction in 2011, 1% of all procedures performed in the RAPTOR suite were trauma related. From 2011 until 2016, 43 trauma patients underwent treatment in the RAPTOR suite. The majority of patients (81%) suffered blunt injury. Most patients were male (70%), with a mean age of 43years. The mean ISS was 38. In 56% (n = 24) the MTP was activated and in 40% (n = 17) a CT scan was performed prior to treatment. Damage control surgery alone, angioembolization alone and a combination of DCS and angioembolization were performed in 37% (n = 16), 23% (n = 10) and 40% (n = 17) of patients, respectively. Median time to the hybrid suite, procedure time and total time were 56min (15-704), 160min (42-404), and 251min (93-788), respectively. In the first 5years following introduction of a hybrid theatre in an urban level I trauma centre, only 1% of patients using the resource has injury-related pathology. Earlier identification of patients requiring this facility may improve timely access and management for this select group of patients needing urgent control of bleeding.

SP5.2.5 Optimising Communication during Damage Control Surgery- a survey of adult Major Trauma Centres in England

Abstract Aims Snap briefs (truncated WHO checklists) and Sit Reps (situational reporting), are long established practices within the military, developed from their vast experience in treating patients requiring Damage Control Surgery (DCS)[1,2]. Our aim was to establish if formal systems like these are in place in Major Trauma Centres (MTCs) in England, and gather staff's experiences of using these systems. Methods An online survey was devised and distributed to MTCs in England via the Major Trauma Network. It consisted of 14 questions, relating to use of modified WHO checklists and Sit Reps during DCS. Results Results were received from all 23 adult MTCs in England. Eight centres (34.8%) reported using a modified WHO checklist for DCS. Most commonly these were modified to include reference to blood products used and available, other specialties needed, and presence of surgical equipment prior to start (eg. thoracotomy.) 12 centres (52.2%) are using Sit Reps during DCS. Many respondents from centres without a formal policy in place stated that they personally endeavor to maintain communication when they are involved in DCS cases, and recognised that a formal system would be greatly beneficial. Conclusion Many MTCs are not using truncated WHO checklists and Sit Reps for DCS. From the centres who have adopted these methods, staff have reported they improve shared decision making. Wider implementation of these techniques could therefore lead to both improved patient care and staff experiences.

Integrating Endovascular and Operative Intervention in Trauma

Patterns of utilization of the hybrid operating room (hybrid-OR) in trauma have not been described. The aim of this study was to describe the sequencing and integration of endovascular and operative interventions in trauma using a hybrid-OR. This is a single-center, retrospective cohort study of trauma patients who underwent both endovascular and operative intervention (2013-2019). Patients were separated into four groups based on procedure patterns: concomitant-linked (C-L), concomitant-independent, serial-linked (S-L) and serial-independent (S-I). The groups were defined as follows: C-L - related endovascular and operative interventions in the same OR; concomitant-independent - unrelated interventions in the same OR; S-L - related interventions in separate ORs; S-I - unrelated interventions in separate ORs. Patient characteristics, procedures performed and time to angiography in each group were analyzed. Out of 202 patients, most procedures utilizing the hybrid-OR were for hemorrhage control (84.1%) and were performed in a C-L manner (36.1%). Patients in the C-L group were most likely to undergo lower extremity revascularization and received the most transfusions. Patients in the S-L and S-I groups were more severely injured, had greater severe abdominal injury and were more likely to undergo damage control surgery and solid organ interventions, respectively. The C-L group had the highest percentage of patients to undergo angiography within 12 h (77%, P=0.053). The hybrid-OR is an ideal space for hemorrhage control in trauma, but there is room for improvement in the triage of patients with non-compressible torso hemorrhage. Current practice patterns prioritize the hybrid-OR for management of lower extremity injury and are not optimal. Use of the hybrid-OR could be improved by concomitant management of patients with severe abdominal injury requiring damage control surgery.

Damage control surgical management of combined small and large bowel injuries in penetrating trauma: Are ostomies still pertinent?

Hollow viscus injuries represent a significant portion of overall lesions sustained during penetrating trauma. Currently, isolated small or large bowel injuries are commonly managed via primary anastomosis in patients undergoing definitive laparotomy or deferred anastomosis in patients requiring damage control surgery. The traditional surgical dogma of ostomy has proven to be unnecessary and, in many instances, actually increases morbidity. The aim of this article is to delineate the experience obtained in the management of combined hollow viscus injuries of patients suffering from penetrating trauma. We sought out to determine if primary and/or deferred bowel injury repair via anastomosis is the preferred surgical course in patients suffering from combined small and large bowel penetrating injuries. Our experience shows that more than 90% of all combined penetrating bowel injuries can be managed via primary or deferred anastomosis, even in the most severe cases requiring the application of damage control principles. Applying this strategy, the overall need for an ostomy (primary or deferred) could be reduced to less than 10%.

Meta-analysis on surgical management of colonic injuries in trauma: to divert or to anastomose?

Primary repair or resection with anastomosis (PR/A) has been gaining increasing recognition for traumatic colonic injuries, with the need for faecal diversion (FD) especially those of penetrating etiology being questioned. However, the role of PR/A in critically ill patients is still controversial with concerns pertaining to safety and anastomotic leak. We performed a systemic review of studies comparing outcomes of FD versus PR/A in traumatic colonic injuries. A systematic review was performed as per PRISMA guidelines utilizing three electronic databases: Pubmed, EMBASE, and Cochrane Library resources. Mortality and anastomotic leak rates are identified as the primary and secondary outcomes, respectively. Data extracted include mortality rates, type of surgical intervention, surgical complications, and need for DC (damage control)surgery. Fourteen studies were identified comprising 11 retrospective, 2 prospective cohort and 1 randomized trial with a total of 2071 patients. Six studies included patients that underwent DC surgery. The overall mortality rate was 3.77% and was higher in the FD group compared to PR/A group (5.38% vs 2.49%, p = 0.07). 71.3% of patients underwent PR/A with an overall leak rate of 4.63%. There was no difference in intra-abdominal collections between the PR/A and FD groups. In the subgroup analysis, anastomotic leak rate was significantly higher in the DC group compared to non-DC group (16.7% vs 3.2%, p = 0.003). This meta-analysis supports PR/A in stable patients with traumatic colonic injuries. FD should be considered in critically ill patients who require DC surgery as leak rates are significantly higher.

Early Identification of Trauma-induced Coagulopathy: Development and Validation of a Multivariable Risk Prediction Model.

The aim of this study was to develop and validate a risk prediction tool for trauma-induced coagulopathy (TIC), to support early therapeutic decision-making. TIC exacerbates hemorrhage and is associated with higher morbidity and mortality. Early and aggressive treatment of TIC improves outcome. However, injured patients that develop TIC can be difficult to identify, which may compromise effective treatment. A Bayesian Network (BN) prediction model was developed using domain knowledge of the causal mechanisms of TIC, and trained using data from 600 patients recruited into the Activation of Coagulation and Inflammation in Trauma (ACIT) study. Performance (discrimination, calibration, and accuracy) was tested using 10-fold cross-validation and externally validated on data from new patients recruited at 3 trauma centers. Rates of TIC in the derivation and validation cohorts were 11.8% and 11.0%, respectively. Patients who developed TIC were significantly more likely to die (54.0% vs 5.5%, P < 0.0001), require a massive blood transfusion (43.5% vs 1.1%, P < 0.0001), or require damage control surgery (55.8% vs 3.4%, P < 0.0001), than those with normal coagulation. In the development dataset, the 14-predictor BN accurately predicted this high-risk patient group: area under the receiver operating characteristic curve (AUROC) 0.93, calibration slope (CS) 0.96, brier score (BS) 0.06, and brier skill score (BSS) 0.40. The model maintained excellent performance in the validation population: AUROC 0.95, CS 1.22, BS 0.05, and BSS 0.46. A BN (http://www.traumamodels.com) can accurately predict the risk of TIC in an individual patient from standard admission clinical variables. This information may support early, accurate, and efficient activation of hemostatic resuscitation protocols.

Damage control or definitive repair? A retrospective review of abdominal trauma at a major trauma center in South Africa

BackgroundThis study set out to review a large series of trauma laparotomies from a single center and to compare those requiring damage control surgery (DCS) with those who did not,...

Blast injures to the thorax.

One out of 10 of military casualties and 6-9 out of 10 civilian victims of terror incidents suffer pulmonary blast injuries when the attackers use explosives as weapon. No specific therapy exists for the primary, shock-wave injury to the lung. The treatment protocols are based on mechanical ventilation, intensive therapy and supportive care. Secondary and tertiary blast structural injuries to the thorax require damage control surgery, dominated by pleural space management (drainage) and haemorrhage control (thoracotomy if needed). Parenchyma resection of irreversibly destroyed lung is rarely needed, and non-anatomical resections are to be preferred. Delayed chest wall reconstruction follows haemodynamic stabilisation and completion of demarcation process. Blast injury to the chest requires a multidisciplinary approach, where the outcome is strongly influenced by the concomitant injuries.

The consequences of associated major visceral vascular injuries on outcome in patients with pancreatic injuries: a case-matched analysis

Background: This case-matched analysis assessed the influence of associated visceral vascular injuries on outcome in pancreatic injuries. Methods: Sixty-eight patients with a Pancreatic Injury with a visceral Vascular Injury (PIVI group) were matched one-to-one to 68 similar Pancreatic Injury patients without a vascular injury (PI group). Using univariate and bivariate logistic regression analysis outcomes measured were complication rates, length of hospital stay and 90 day mortality rate. Results: The two groups were well matched. Mortality in the PIVI group was 41% compared to 13% in the PI alone group. On univariate analysis the PIVI group were significantly more likely to be shocked on admission, have a RTS <7.8, require damage control surgery, receive a blood transfusion, develop a major postoperative complication and die. On logistic regression analysis, the need for damage control surgery was a significant variable (p=0.015, OR 7.95, CI 1.50-42.0). Mortality of AAST grade 1 and 2 pancreatic injuries combined with a vascular injury was 18.5% compared to an increased mortality of 56.1% of AAST grade 3, 4 and 5 pancreatic injuries with vascular injuries (p=0.0026). Conclusion: Pancreatic injuries associated with major visceral vascular injuries have a significantly higher complication and mortality rate than pancreatic injuries without vascular injuries. The addition of a vascular injury with an increasing AAST pancreatic injury grade of exponentially compounds mortality rate.

Use of an intravascular temperature control catheter for rewarming of hypothermic trauma patients with ongoing hemorrhagic shock after combined damage control thoracotomy and laparotomy: A case series

BackgroundCorrection of hypothermia is a key component of the resuscitation of critically injured patients with hemorrhagic shock who require damage control surgery. External rewarming methods may not be sufficient in this population, while extracorporeal techniques lack widespread feasibility. Intravascular catheter-based temperature modulation is increasingly being employed in different critically ill patient populations but has not been described as part of a damage control resuscitation strategy in trauma patients. MethodsWe retrospectively reviewed the medical records of all patients admitted to our multi-trauma intensive care unit from July 1, 2015 – December 31, 2017 in whom an intravascular temperature control catheter (IVTCC) was employed for rewarming from hypothermia during the immediate postoperative resuscitation of continued hemorrhage after undergoing combined damage control thoracotomy and laparotomy for trauma. All patients received baseline treatment with active external rewarming modalities and inline fluid/blood warmers. Core temperature values over the first 24 h of hospital admission were analyzed. Efficacy (rewarming rate) and safety (associated adverse events) of the IVTCC system were determined. ResultsThree patients (age 22 ± 4.6, 100% male, 100% torso gunshot wounds with prehospital cardiac arrest) meeting the inclusion criteria were treated with the IVTCC system during the study period. Temperature at the start of rewarming using the IVTCC ranged from 30.1 to 35.5 °C. Despite ongoing severe hemorrhagic shock (24-hour ICU blood product requirement: 104 ± 44 units), a mean rewarming rate of 1.04 ± 0.63°C/hour was achieved. One patient suffered an uncomplicated catheter-associated deep vein thrombosis. Two of the 3 patients survived to hospital discharge with intact cognitive function. ConclusionsUse of an IVTCC may be a minimally-invasive, practical, and effective method for rewarming critically ill trauma patients with ongoing hemorrhagic shock after multi-cavitary damage control surgery. Further studies are needed to compare this technology with currently available rewarming methods.

Colon Trauma: Evidence-Based Practices.

Colon injury is not uncommon and occurs in about a half of patients with penetrating hollow viscus injuries. Despite major advances in the operative management of penetrating colon wounds, there remains discussion regarding the appropriate treatment of destructive colon injuries, with a significant amount of scientific evidence supporting segmental resection with primary anastomosis in most patients without comorbidities or large transfusion requirement. Although literature is sparse concerning the management of blunt colon injuries, some studies have shown operative decision based on an algorithm originally defined for penetrating wounds should be considered in blunt colon injuries. The optimal management of colonic injuries in patients requiring damage control surgery (DCS) also remains controversial. Studies have recently reported that there is no increased risk compared with patients treated without DCS if fascial closure is completed on the first reoperation, or that a management algorithm for penetrating colon wounds is probably efficacious for colon injuries in the setting of DCS as well.

Randomized Controlled Trial Evaluating the Efficacy of Peritoneal Resuscitation in the Management of Trauma Patients Undergoing Damage Control Surgery

Peritoneal resuscitation (PR) represents a unique modality of treatment for severely injured trauma patients requiring damage control surgery. These data represent the outcomes of a single institution randomized controlled trial into the efficacy of PR as a management option in these patients. From 2011 to 2015, one hundred and three patients were enrolled in a prospective randomized controlled trial evaluating the use of PR in the treatment of patients undergoing damage control surgery compared with conventional resuscitation (CR) alone. Patient demographics, clinical variables, and outcomes were collected. Univariate and multivariate analysis was performed with a priori significance at p ≤ 0.05. After initial screening, 52 patients were randomized to the PR group and 51 to the CR group. Age, sex, initial pH, and mechanism of injury were used for randomization. Method of abdominal closure was standardized across groups. Time to definitive abdominal closure was reduced in the PR group compared with the CR group (4.1 ± 2.2 days vs 5.9 ± 3.5 days; p ≤ 0.002). Volume of resuscitation and blood products transfused in the initial 24 hours was not different between the groups. Primary fascial closure rate was higher in the PR group (83% vs 66%; p ≤ 0.05). Intra-abdominal complications were lower in the PR compared with the CR group (8% vs 18%), with abscess formation rate (3% vs 14%; p<0.05) being significant. Patients in the PR group had a lower 30-day mortality rate, despite similar Injury Severity Scores (13% vs 28%; p= 0.06). Peritoneal resuscitation enhances management of damage control surgery patients by reducing time to definitive abdominal closure, intra-abdominal infections, and mortality rates.

Subspecialisation in emergency medicine: A specialty at the crossroads.

Subspecialisation in emergency medicine: A specialty at the crossroads.

Risk factors for mortality in blunt abdominal trauma with surgical approach.

identify risk factors for mortality in patients who underwent laparotomy after blunt abdominal trauma. retrospective study, case-control, which were reviewed medical records of blunt trauma victims patients undergoing laparotomy, from March 2013 to January 2015, and compared the result of the deaths group with the group healed. of 86 patients, 63% were healed, 36% died, and one patient was excluded from the study. Both groups had similar epidemiology and trauma mechanism, predominantly young adults males, automobilistic accident. Most cases that evolved to death had hemodynamic instability as laparotomy indication - 61% against 38% in the other group (p=0.02). The presence of solid organ injury was larger in the group of deaths - 80% versus 48% (p=0.001) and 61% of them had other associated abdominal injury compared to 25% in the other group (p=0.01). Of the patients who died 96% had other serious injuries associated (p=0.0003). Patients requiring damage control surgery had a higher mortality rate (p=0.0099). Only one of 18 patients with isolated hollow organ lesion evolved to death (p=0.0001). The mean injury score of TRISS of cured (91.70%) was significantly higher than that of deaths (46.3%) (p=0.002). the risk factors for mortality were hemodynamic instability as an indication for laparotomy, presence of solid organ injury, multiple intra-abdominal injuries, need for damage control surgery, serious injury association and low index of trauma score.

Direct Peritoneal Resuscitation Accelerates Primary Abdominal Wall Closure after Damage Control Surgery

Damage control surgery is a staged approach to the trauma patient in extremis that improves survival, but leads to open abdominal wounds that are difficult to manage. We evaluated whether directed peritoneal resuscitation (DPR) when used as a resuscitation strategy in severely injured trauma patients with hemorrhagic shock requiring damage control surgery would affect the amount of and timing of resuscitation and/or show benefits in time to abdominal closure and reduction of intra-abdominal complications. A retrospective case-matched study of patients undergoing damage control surgery for hemorrhagic shock secondary to trauma between January 2005 and December 2008 was performed. Twenty patients undergoing standardized wound closure and adjunctive DPR were identified and matched to 40 controls by Injury Severity Score, age, gender, and mechanism of injury. A single early death was excluded because of inability to control ongoing hemorrhage. There were no differences in age, gender, or mechanism of injury between the groups. Injury Severity Score (35.07 +/- 17.1 versus DPR 34.95 +/- 16.95; p = 0.82) and packed red blood cell administration in 24 hours (23.8 +/- 14.35 U versus DPR 26.9 +/- 14.1 U; p = 0.43) were similar between the groups. Presenting pH was similar between the study group and the DPR group (7.24 +/- 0.13 d versus DPR 7.26 +/- 0.11; p = 0.8). Time to definitive abdominal closure was significantly less in the DPR group compared with controls (DPR: 4.35 +/- 1.6 d versus 7.05 +/- 3.31; p < 0.003). DPR also allowed for a higher rate of primary fascial closure, lower intra-abdominal complication rate, and lower rate of ventral hernia formation at 6 months. Adjunctive DPR afforded a definitive wound closure advantage compared with Wittmann patch closure techniques (DPR 4.35 +/- 1.6 versus Wittmann patch 6.375 +/- 1.3; p = 0.004). The addition of adjunctive DPR to the damage control strategy shortens the interval to definitive fascial closure without affecting overall resuscitation volumes. As a result, this mitigates intra-abdominal complications associated with open abdomen and damage control surgery and affords better patient outcomes.

Damage Control Surgery and Open Abdominal Management: Recent Advances and Our Approach

The concept of damage control and improved understanding of the pathophysiology of abdominal compartment syndrome (ACS) have been proven to be great advances in the management of both traumatic and nontraumatic surgical conditions. The practice of damage control surgery includes 3 components: 1) abbreviated resuscitative surgery for rapid control of hemorrhage and abdominal contamination by gastrointestinal contents, followed by temporary abdominal wall closure for planned reoperation and prevention of ACS; 2) restoration of physiologic function, including rewarming and correction of coagulopathy and hemodynamic stabilization in the intensive care unit; and 3) re-exploration for the definitive management of injuries and abdominal wall closure. Although this new approach can decrease the mortality rate of patients with severe physiological derangement, the establishment of clearly defined indications is necessary. For patients who require damage control surgery, interventional radiology should be integrated into the strategy for achieving hemostasis. Angiographic evaluation and embolization should be considered immediately after initial operation, especially for patients with combined intraperitoneal and retroperitoneal hemorrhage, severe hepatic injury, or ongoing hemorrhage after damage control surgery. In many patients who require conventional open abdominal management following damage control surgery or decompressive laparotomy for ACS, the granulating abdominal contents are covered with only a skin graft, which is associated with a risk of enterocutaneous fistula. These patients will ultimately require complex abdominal wall reconstruction at a later stage. We have performed early fascial closure using an anterior rectus abdominis sheath turnover flap method. This technique may reduce the need for skin grafting and subsequent reconstruction and can be considered as an alternative method for the early management of patients with open abdomen.

Damage control resuscitation: A paradigm shift in the management of haemorrhagic shock

Many advances in trauma care have resulted from the treatment of battle casualties by combat medics, military physicians and nurses. A recent example is damage control resuscitation (DCR), which is transforming the care of soldiers with haemorrhagic shock requiring damage control surgery (DCS) in the current conflicts in Iraq and Afghanistan. We believe that these new treatments have application in patients with haemorrhagic shock requiring damage control interventions in the civilian setting and that health professionals in the Australian trauma community should become familiar with these concepts. Exsanguination is the second cause of death after traumatic brain injury in trauma, with massive transfusion required in up to 6% of military and up to 2% of civilian trauma. Coagulopathy commonly occurs during the resuscitation of exsanguinating trauma patients and, with acidosis and hypothermia, comprise the ‘lethal triad’. Coagulopathy increases the risk of preventable death in trauma patients. By directly addressing the ‘lethal triad’, DCR supports DCS. DCR restores intravascular volume and composition, supports depleted circulatory and haemostatic reserve and aims to prevent and treat complications, including acidosis and coagulopathic bleeding in exsanguinating trauma patients. Standard practice for the resuscitation of patients with haemorrhagic shock in Australia and New Zealand is the administration of crystalloid or colloid followed by stored packed red blood cells (PRBC), either crossmatched or group O-negative. Administration of fresh frozen plasma (FFP) and platelets is generally withheld until there is laboratory evidence of coagulopathy or deficiency. However, these exsanguinating patients will usually have clinical evidence of coagulopathy on presentation that requires immediate correction. Borgman et al. demonstrated outcome benefit for patients requiring massive transfusion in a military setting who had administration of a high plasma to RBC ratio (1:1.4). Early plasma administration is now endorsed by the US Army Surgeon General in trauma patients requiring or at risk of massive transfusion. Following prehospital measures to control bleeding, minimal fluid resuscitation and rapid transport to the trauma centre, DCR combines multiple aspects of haemostatic support commencing in the emergency room, continuing during DCS and into the postoperative phase and intensive care unit. DCR is indicated in patients with severe (class IV) haemorrhagic shock (Table 1) who require massive transfusion and immediate DCS. DCR consists of urgent resuscitation to maintain essential circulating blood volume, to preserve life and vital organ function, while preventing and treating coagulopathic bleeding complications in exsanguinating trauma patients. DCR predicts and attempts to correct the physiological disturbances of

Pancreatic trauma

Pancreatic trauma is relatively uncommon and although the surgical management is in many cases comparatively simple, occasionally complex technical surgery is required. Early diagnosis is paramount, although this remains difficult. The challenge of pancreatic trauma is compounded by a high incidence of associated injuries to adjoining organs and major vascular structures that may require damage control surgery and delayed definitive repair and add to the high frequency of postoperative complications, morbidity and mortality.