1. Dr. Yasser Abbas
Department of General surgery

2. Outlines
Concept of Damage control
History
Indications of Damage Control.
Damage Control Sequence.
Complications.
Summary.

3. Concept of Damage control
 “ …keeping afloat a badly damaged
ship by procedures to limit flooding ,
stabilize the vessel, isolate fires and
explosions and avoid their spreading”
 Surface ship survivability, Naval war publication
 3-20.31, Washington, DC. Department of defense; 1996

4. Definitive Surgery Approach?
 “The operation was a success
but the patient died anyway.”
– Anonymous

5. Damage Control Approach ?
 “He who fights and runs away,
may live to fight another day.”
– JA Aulls, 1876

6. History

7.  In 1983, Stone was first to describe the “bailout”
approach .
 14 patients :
 Per-operative correction of coagulopathy
 Definitive surgery
 1 survivor
 17 patients:
 OR and packing
 Correction of coagulopathy in ICU
 Re exploration in OR
 11 survivors

9. The Concept Expansion
The concept of DC was initially described for
intra-abdominal trauma, it has been expanded
to :
 Thoracic.
 Extremity vascular.
 Orthopedic injuries.
“Damage Control Resuscitation”. 1c

10. Indications of DC
High-energy blunt torso trauma
Multiple penetrating torso injuries
Hemodynamic instability
Coagulopathy on presentation or during operation
Severe metabolic acidosis (pH < 7.2 or base deficit > 8)
Hypothermia on presentation (< 35°C)
Prohibitive operative time required to repair injuries (> 90 min)
Multiple visceral injuries with major vascular trauma
Multiple injuries across body cavities
Massive transfusion requirements (> 10 units packed red blood
cells)
Presence of injuries better treated with nonsurgical adjuncts

11. The Lethal Triad

12.  It is Better to Cure in Phases
rather than to Kill in one
- Anonymous

13. DC Sequence
Ground 0
 Prehospital care & Initial resuscitation:
 Built on fundamentals of ATLS guidelines.
 Rapid Transport to definitive care.
 Rapid Evaluation.
 FAST, Tube Thorocostomy , CXR, Pelvis X-ray, etc…
 Damage Control Resuscitation to systolic 80-90 mmHg.
 This phase should take 20-30 min.

14. How do We Predict in ED ?
 A DC approach should be taken with any patient in the
ED who has :
 Revised Trauma Score ( RTS ) ≤ 5
 Requires ≥ 2,000 ml of crystalloids for resuscitation in
the ER.
 Requires ≥ 2 units of PRBCs for resuscitation in the ER.
 A pH of ≤ 7.2
 Strength of evidence: C.
 Asensio J, et al. Am J Surg 2001; 182: 743–51.

15. DC Sequence
Part 1(OR)
 Control of Hemorrhage and Contamination:
 Laparotomy
 Evacuation of blood.
 Four quadrant packing.
 Full exposure of the injuries.
 Kocher maneuver
 Cattell-Braasch
 Mattox

16. DC Sequence
Part 1(OR)
 Solid organs: such as spleen and isolated kidney , are
sacrificed in damage control if repair prolongs
surgical times.
 Bleeding vessel : Ligation /shunting.
 Bowel injury: stapler/ ligation.
 Intra-abdominal Packing
 Temporary abdominal closure
 This phase shouldn`t take more than 90 min.

17. Incisions in DC

18. Retroperitoneal Zones

19. Kocher Maneuver

20. Cattell-Braasch

21. Mattox

22. Liver Packing

23. Intraoperative ; How to identify
the patient for DC ?
Patients who require ≥ 4,000 ml PRBCs.
Patients who have had an ED or OR.
thoracotomy.
 pH ≤ 7.2
Temperature of ≤ 34°C
Inaccessible major venous injury

24. Intraoperative ; How to identify the
patient for DC ?
 If the surgeon cannot achieve hemostasis
owing to coagulopathy
 If the definitive operative repair is a time-consuming
procedure in the patient with
suboptimal response to resuscitation
If the patient requires the management of an
extra-abdominal life-threatening injury

25. Intraoperative ; How to identify
the patient for DC ?
 If the patient will require a reassessment of
intra-abdominal contents
 If the surgeon cannot re-approximate the
abdominal fascia due visceral edema.
 Strength of recommendation: D.
 Shapiro M, Jenkins D, Schwab C, et al. J Trauma 2000; 49: 969–78.
 Rotondo M, Zonies D. Surg Clin N Am 1997; 77: 761–77.
 Loveland J, Boffard K. Br J Surg 2004; 91: 1095–101

26. When We Terminate the Surgery?
 Core temperature ≤ 34°C
 pH ≤ 7.2
 Prothromin time ≥ twice normal
 Partial thromboplastin time ≥ twice normal
 Strength of recommendation: B.
 Ferrara A, MacArthur J, Wright H, et al. Am J Surg 1990; 160: 515–18.
 Cosgriff N, Moore E, Sauaia A, et al. J Trauma 1997; 42: 857–61; discussion
861–2.
 Garrison J, Richardson J, Hilakos A, et al. J Trauma 1996; 40: 923–7;
discussion 927–9.

27. Part 2: Resuscitation(ICU)
Correct Acidosis and Coagulopathy
Rewarm the patient
Optimize oxygenation and ventilation
Measure Intra abdominal pressure. ( 1A)

28. Part 3: (OR 2)
Careful removal of packs
Inspection of all injuries
Control of bleeding points
Definitive GIT repair
Thorough washout
Avoid stomas and tube entrostomies if
possible
Temporary vs. definitive closure

29. Part 4: Open Abdominal Wounds
 Temporary closure of the open abdomen is best
accomplished :
 VAC Dressing.
 and a fascial tensioning.
 Abdominal closure is best accomplished by hospital day 8 to
reduce morbidity.
 Strength of recommendation: C.
 Barker D, Green J, Maxwell R, et al. J Am Coll Surg 2007;204:784–92.
 Offner P, de Souza A, Moore E, et al. Arch Surg 2001; 136: 676–81.
 Garner G, Ware D, Cocanour C, et al. Am J Surg 2001; 182:630–8.

30. Temporary Abdominal Closure

31. Mesh closure and Tightening

32. Definitive Repair

33. Outcome

Before After

34. Outcome
Before After

35. Outcome

36. DC Timeline
Reuven Rabinovici, et al. , Trauma, Critical care & surgical emergency. 2010

37. Complications of DC
 Expected complication rate from damage control
ranges from 25% to 40% .
 The most common complications :
 Intra-abdominal abscesses
 Enterocutaneous fistulae.
 Strength of recommendation: C.
 Abikhaled J, Granchi T, Wall M, et al. Am Surg 1997; 63: 1109–12;
discussion 1112–13.
 Sharp K, Locicero R. Ann Surg 1992; 215: 467–74; discussion 474–5.

38. Summary
 The management of exsanguination requires
leadership, prompt thinking and aggressive surgical
intervention.
 Delays in the decision to perform DC contribute to a
higher morbidity and mortality.
 DC is a vital part of the management of the multiply
injured patient and should be performed before
metabolic exhaustion.