How beneficial is the DCS? Sohag university trials Recommendations

1. Damage control surgery
(DCS)
Recent and sohag Univ.
trials
Prepared by/
Mostafa Farrag M. Saleem
Assisstant teacher of general surgery, 2018

2. ‫البزار‬ ‫روى‬‫عنه‬ ‫هللا‬ ‫رضي‬ ‫مالك‬ ‫بن‬ ‫أنس‬ ‫حديث‬ ‫من‬ ‫مسنده‬ ‫في‬
‫قال‬ ‫وسلم‬ ‫عليه‬ ‫هللا‬ ‫صلى‬ ‫النبي‬ ‫أن‬(( :‫للعبد‬ ‫يجري‬ ‫سبع‬
‫موته‬ ‫بعد‬ ‫قبره‬ ‫في‬ ‫وهو‬ ‫أجرهن‬:‫علما‬ ‫م‬ّ‫ل‬َ‫ع‬ ‫من‬,‫نهرا‬ ‫أجرى‬ ‫أو‬,
‫بئرا‬ ‫حفر‬ ‫أو‬,‫نخال‬ ‫غرس‬ ‫أو‬,‫مسجدا‬ ‫بنى‬ ‫أو‬,‫ث‬ّ‫ور‬ ‫أو‬
‫مصحفا‬,‫موته‬ ‫بعد‬ ‫له‬ ‫يستغفر‬ ‫ولدا‬ ‫ترك‬ ‫أو‬))
[‫برقم‬ ‫الجامع‬ ‫صحيح‬ ‫في‬ ‫هللا‬ ‫رحمه‬ ‫األلباني‬ ‫حسنه‬:3596.]
‫منهم‬ ‫نكون‬ ‫أن‬ ‫هللا‬ ‫ونرجو‬

3. ‫الجوزي‬ ‫ابن‬ ‫قال‬–‫هللا‬ ‫رحمه‬-

4. Items to be discussed
 History
 Definition
 Pathophysiology
 Indications and principles
 Phases of DCS
 Teamwork of DCS
 Timeline
 Methods
 Complications
 Case presentation
 Home message
 References

5. ‫العلمية‬ ‫الحلقة‬ ‫سؤال‬
‫مغربي‬ ‫عربي‬ ‫شاعر‬
‫عام‬ ‫ولد‬1909‫م‬
‫الحديث‬ ‫العصر‬ ‫شعراء‬ ‫أهم‬ ‫أحد‬

6. History of DCS
 General surgeons have used the concept of damage control
surgery for many years; Pringle described his technique in
patients with substantial liver trauma 1908.
 The U.S. military surgeons did not encourage his technique in
World War II and the Vietnam War.
 Lucas and Ledgerwood described the principle in a series of
patients.
 Subsequent studies discovered that hepatic packing increased
survival by 90%.
 This technique was then specifically linked to patients who
were hemorrhaging, hypothermic, and coagulopathic.

7. In 1983, Stone firstly described the “bailout”
approach .
14 patients :
-- Per-operative correction of coagulopathy
-- Definitive surgery
-- 1 survivor

8. • 17 patients:
-- OR and packing
-- Correction of coagulopathy in ICU
-- Re exploration in OR
-- 11 survivors

10. Mode of trauma

17. Other significant modes of
trauma
Falling from height
Blunt abdominal / visceral trauma
Dragging

18. It is Better to Cure in Phases
rather than to kill in one
- Anonymous

19. ‫تونس‬ ‫في‬ ‫الحقوق‬ ‫درس‬
‫عن‬ ‫يزيد‬ ‫ما‬ ‫ألف‬77‫قصيدة‬
‫العالم‬ ‫طغاة‬ ‫إلى‬ ‫قصائده‬ ‫أشهر‬

20. ‫قال‬ ‫من‬
‫أرى‬ ‫إني‬ََ..‫ة‬َّ‫م‬َ‫ج‬ ‫وعا‬ُ‫م‬ُ‫ج‬ ‫ى‬َ‫أر‬َ‫ف‬ ،َ
َ‫ال‬ِ‫ب‬ ‫تحيا‬ ‫ها‬ّ‫ن‬‫لك‬ِ‫ب‬‫با‬ْ‫ل‬‫أ‬
‫ي‬ِ‫و‬ْ‫د‬َ‫ي‬‫ما‬َّ‫ن‬‫كأ‬ ،ُ‫ن‬‫ما‬َّ‫الز‬ ‫ْها‬‫ي‬َ‫ل‬‫حوا‬
ِ‫ب‬‫وترا‬ ٍ‫ل‬‫جند‬ ‫ي‬َ‫ل‬‫حوا‬ ‫يدوي‬
‫اكروا‬َ‫ن‬َ‫ت‬ ِ‫للزمان‬ ‫وا‬ُ‫ب‬‫ا‬َ‫ج‬‫است‬ ‫وإذا‬
ِ‫َّوك‬‫ش‬‫بال‬ ‫وا‬ُ‫ق‬َ‫ش‬‫ا‬َ‫ر‬َ‫ت‬َ‫و‬ِ‫ب‬‫ا‬َ‫ص‬ْ‫واألح‬
‫ة‬َّ‫األخو‬ ‫وح‬ُ‫ر‬ ‫على‬ ‫وا‬َ‫ض‬‫وق‬‫بينهم‬ َِ
‫يشة‬ِ‫ع‬ ‫ُوا‬‫ش‬‫وعا‬ ‫هال‬َ‫ج‬ِ‫ب‬‫غرا‬َ‫أل‬‫ا‬ ََ
‫عاسة‬ّ‫ت‬‫ال‬ ُ‫ل‬‫غو‬ ‫بهم‬ ْ‫حت‬ ِ‫فر‬‫ا‬َ‫ن‬َ‫ف‬‫وال‬ َِ
ِ‫ب‬ّ‫ال‬َ‫غ‬‫وال‬ ‫ب‬َّ‫ال‬ّ‫س‬‫ال‬ ُ‫ع‬ِ‫ام‬َ‫ط‬َ‫م‬َ‫و‬
‫هى‬ّ‫ل‬‫وال‬ ،ُ‫ع‬‫طام‬َ‫م‬‫ال‬ ‫ُها‬‫ك‬ ِّ‫حر‬ُ‫ت‬ ،ٌ‫ب‬َ‫ع‬ُ‫ل‬
ِ‫ب‬‫واآلرا‬ ِ‫د‬‫األحقا‬ ُ‫ر‬ِ‫ئ‬‫غا‬َ‫ص‬‫و‬
ٍ‫د‬‫جام‬ ،ٍ‫ُخان‬‫د‬ ْ‫ن‬ِ‫م‬ ،‫نفوسا‬ ‫وأرى‬
ِ‫ب‬‫ا‬َ‫ب‬َ‫ض‬ َ‫ء‬‫ورا‬ ،ٍ‫كأشباح‬ ،ٍ‫ت‬ْ‫ي‬َ‫م‬

21.  ‫ى‬ َ‫و‬َ‫ت‬‫ج‬ُ‫م‬‫ال‬ ‫القديم‬ ِ‫م‬َ‫م‬ ِ‫ر‬ ‫على‬ ‫حيا‬َ‫ي‬
 ‫الخابي‬ ‫ماد‬َّ‫الر‬ ِ‫م‬َ‫م‬ ِ‫ح‬ ‫في‬ ‫ُّود‬‫د‬‫كال‬

 ٌ‫ع‬‫ائ‬َ‫ض‬ ،ٌ‫ع‬‫قطي‬ ‫بينهما‬ ُ‫عب‬َّ‫ش‬‫وال‬
 ِ‫ب‬‫وشرا‬ ٍ‫ل‬‫مأك‬ ‫دنيا‬ ‫ُنياه‬‫د‬
‫ه‬َّ‫ن‬‫ف‬ ‫ق‬ ِ‫ر‬ْ‫ه‬َ‫ي‬ ُ‫الموهوب‬ ُ‫اعر‬َّ‫ش‬‫ال‬
ِ‫ب‬‫ْتا‬‫ع‬َ‫أل‬‫وا‬ ِ‫دام‬ْ‫ق‬َ‫أل‬‫ا‬ ‫على‬ ً‫ا‬‫هدر‬
ٍ‫ت‬ِ‫مي‬ ،ٍ‫عقيم‬ ،ٍ‫كون‬ ‫في‬ ُ‫ويعيش‬
‫غباوة‬ ُ‫ه‬ْ‫ت‬‫َّد‬‫ي‬‫ش‬ ْ‫د‬َ‫ق‬ِ‫ب‬‫ا‬َ‫ق‬‫ح‬َ‫أل‬‫ا‬ ُُ
‫مره‬ُ‫ع‬ ُ‫نفق‬ُ‫ي‬ ُ‫حرير‬ِ‫الن‬ ُ‫م‬ِ‫ل‬ِ‫ا‬‫والع‬
ِ‫ب‬‫كتا‬ ِ‫ودرس‬ ،ٍ‫ألفاظ‬ ِ‫فهم‬ ‫في‬

22. “ The concept of DCS is …keeping afloat a
badly damaged
ship by approaches to limit flooding ,
stabilize the vessel, exclude fires and
explosions and avoid spreading”
-- Surface ship survivability, Naval war publication
3-20.31, Washington, DC. Department of defense; 1996

23. Definition
Damage control is a Navy term defined as “the
capacity of a ship to absorb damage and
maintain mission integrity”.
Damage control surgery(DCS) is a concept of
abbreviated laparotomy, designed to prioritize
short-term physiological recovery over
anatomical reconstruction in the seriously
injured and compromised patient.

24.  The concept of DC was initially described for abdominal
trauma, now it has been expanded to :
 Thoracic injuries.
 Extremity vascular injuries.
 Orthopedic injuries.
 Others

25. Approach principle
Damage Control Surgery, Karim Brohi, trauma.org 5:6, June
2000

26. The key philosophy
 To keep the injured patient alive at any cost,
 Abbreviated surgical technique to limit the depletion of
physiological reserve;
 To be part of the resuscitation process

28. Pathophysiology

29. Hypothermia:
Clinically important if <37*C for more than 4 h leading
to:
 Arrhythmias,
 Decreased COP,
 Increassed systemic vascular resistance
 Can induce and exacerbate coagulopathy by inhibition
of clotting cascade reaction

30. Acidosis:
Uncorrected haemorrhagic shock leads into
 inadequate cellular perfusion
 anaerobic metabolism
 the production of lactatic acid
 Interferes with blood clotting mechanisms and
promotes coagulopathy and blood loss

31. Coagulopathy:
 Hypothermia, acidosis and the consequences of
massive blood transfusion all lead to the development of
coagulopathy
 Platelet dysfunction at low temperature
 Activation of the fibrinolytic system
 Haemodilution following massive resuscitation
 pH<7.1-7.2 impairs thrombin production

33. Indications for DCS
Anatomical
 Inability to achieve haemostasis
 Complex abdominal injury, e.g. liver and pancreas
 Combined vascular, solid and hollow organ injury, e.g. aortic
or caval injury
 Inaccessible major venous injury, e.g. retrohepatic vena cava
 Demand for non-operative control of other injuries, e.g.
fractured pelvis
 Need for a time-consuming procedure

34. Physiological (decline of
physiological reserve)
 Temperature < 34ºC
 pH < 7.2
 Serum lactate > 5 mmol/ l [N (Normal) < 2.5 mmol/ l]
 Prothrombin time (PT) > 16 s
 Partial thromboplastin time (PTT) > 60 s
 > 10 units blood transfused
 Systolic blood pressure < 90 mmHg for > 60 min

35. Environmental
 Operating time > 60 min
 Inability to approximate the abdominal incision
 Desire to reassess the intra-abdominal contents
(directed relook)

36. Principles are to
 Control haemorrhage
 Prevent contamination
 Avoid further injury

37. Phases of DCS
 Stage I: Ground 0 ( additional)- Pre Hospital And Hospital
Phase
 Stage II: Abbreviated Laparotomy
 Stage III: ICU Resuscitation
 Stage IV: Definitive surgery

38. Phase I– Ground Zero
 Prehospital care & Initial resuscitation:
• Built on fundamentals of ATLS guidelines.
• Rapid Transport to definitive care.
• Rapid Evaluation.
• FAST, Tube Thoracotomy, CXR, Pelvis X-ray
• Damage Control Resuscitation to systolic 80-90 mmHg
(permissive hypotension)
• This phase should take 20-30 min.

39. Phase II- Abbreviated Laparotomy
• Damage Control Laparotomy (DCL)
 Principles
• Control haemorrhage
• Prevention contamination
• Avoid further injury
 • Aims to restore physiology at the expense of anatomical
reconstruction.
 • On- going DCR in ICU
 This phase should take 90 mins or less.

41. ‫عام‬ ‫توفي‬1935
‫رقي‬ ُ‫ات‬َ‫ن‬ِ‫ئ‬‫َا‬‫ك‬‫ال‬ ِ‫ه‬ِ‫ت‬‫ا‬َ‫ه‬ ‫ني‬ُ‫ع‬ُ‫م‬ْ‫س‬ُ‫ت‬‫و‬،‫األغاني‬ َ‫ق‬
ْ‫د‬‫النشي‬ َ‫و‬ْ‫ل‬ُ‫ح‬‫و‬
ُ‫وترقص‬ُ‫ع‬ ُ‫ح‬‫وأفرا‬ ٌ‫راب‬ِ‫ط‬ ،ٍ‫أمان‬ ‫ي‬ِ‫ل‬‫حو‬ِ‫ر‬ْ‫م‬
ْ‫د‬‫عي‬َ‫س‬ ،ٍّ‫ي‬ِ‫ل‬َ‫خ‬
َ‫ي‬ِّ‫ن‬‫كأ‬ِ‫اهتزاز‬ َ‫ل‬ْ‫ث‬‫م‬ ُّ‫وتهتز‬ ْ‫َر‬‫ش‬َ‫ب‬‫ال‬ َ‫فوق‬ ُ‫ت‬ْ‫َح‬‫ب‬‫أص‬
ْ‫ر‬َ‫ت‬‫الو‬
‫فتخطو‬ُ‫د‬ِّ‫تغر‬ ‫ى‬َ‫ر‬ْ‫ك‬‫س‬ ،َ‫ي‬‫قلب‬ ُ‫د‬‫أناشي‬َ‫ت‬ْ‫ح‬َ‫ت‬ ،
ِ‫ل‬‫ال‬ِ‫ظ‬ْ‫ر‬َ‫م‬َ‫ق‬‫ال‬
‫من‬ ‫فيه‬ ‫بما‬ ِ‫د‬‫الوجو‬ َ‫عناق‬ ‫بروحي‬ ُّ‫د‬َ‫أو‬
ْ‫شجر‬ ‫أو‬ ، ٍ‫أنفس‬
‫فسي‬َ‫ن‬ ُ‫أل‬‫ويم‬ ُ ‫الحياة‬ ّ‫َي‬‫د‬َ‫ل‬ ‫و‬ُ‫ل‬ْ‫ح‬َ‫ت‬َ‫ف‬ ،ِ‫أراك‬ُ‫ح‬‫ا‬َ‫ب‬َ‫ص‬
ْ‫ل‬‫األم‬
‫وتنمو‬‫على‬ ‫وتحنو‬ ٌ‫ذاب‬ِ‫ع‬ ،ٌ‫د‬‫و‬ُ‫ور‬ ‫ي‬ ِ‫بصدر‬
ْ‫ل‬ِ‫ع‬‫المشت‬ َ‫ي‬‫قلب‬
‫ني‬ُ‫ن‬ِ‫ت‬ْ‫ف‬‫وي‬‫وذاك‬ ِ ‫الحياة‬ ُ‫فيض‬ ِ‫فيك‬،ُ‫ّباب‬‫ش‬‫ال‬
،ُ‫ع‬‫الودي‬ْ‫ل‬ِ‫م‬َّ‫ث‬‫ال‬
‫ترف‬ ِ‫ه‬‫ّفا‬ِ‫ش‬‫ال‬ ‫تلك‬ ُ‫ر‬ْ‫ِح‬‫س‬ ‫ني‬ُ‫ن‬‫ويفت‬ْ‫من‬ ُ‫رف‬
ّ‫حولهن‬ْ‫ل‬َ‫ب‬ُ‫ق‬‫ال‬
َ‫حرب‬ ُ‫ل‬ْ‫ب‬َ‫أ‬ ‫لم‬ َ‫ي‬ّ‫ن‬‫كأ‬ ‫جديدا‬ ‫قا‬ْ‫ل‬‫خ‬ ُ‫ق‬َ‫ل‬ْ‫خ‬ُ‫أ‬‫ف‬ ،ِ‫أراك‬
ْ‫د‬‫الوجو‬

42. Phase III- Resuscitation
 DCR: This may only require 12 h , many will require 24–36 h
• Require collaborative efforts of multiple critical care
physicians, nurses, and ancillary staff.
 • GOALs:
 Reverse the sequelae of hypotension related metabolic
failure.
 Physiological and biochemical restoration.
 Adequate oxygen delivery to body tissues
 Intensive monitoring
 Aggressive core rewarming
 Aggressive approach to correction of coagulopathy
 Tertiary Survey

43. Phase IV- Definitive Surgery
 Timing is critical.
 With focused, critical care management and
resuscitation one may obtain this physiological state
within 24–36 hours.
 Look for hidden injuries
 Addresses the definitive repair and tension free
abdominal closure (temp./def.).
Morris, D.S., 2015

44. Timeline

45. Teamwork of DCS

46. All must run or even fly and do their
best to save the gift of Allah; the human.
-- MF
 Transportation and ambulance team
 General surgery
 Trauma and critical medicine
 ICU team
 Orthopaedics
 Vascular surgery
 Neurosurgery
 Cardiothoracic surgery
 Maxillofacial , ENT and plastic surgery
 Anasthesia team
 Clinical pathology and hematology team
And each team consists of (doctors – nurses – assissting
nursing - workers)

47. Methods of DCS
Damage control Laparotomy
 Principles
• Control haemorrhage
-- operative control of haemorrhage and simultaneous
vigorous resuscitation with blood and clotting factors
-- Availability of Blood, FFP, cryoprecipitate, platelet
• Prevention contamination
• Avoid further injury
 • Evacuation of blood.
 • Four quadrant packing.
 • Full exposure of the injuries.
• Kocher maneuver
• Cattell-Braasch
• Mattox

48.  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
 • No reconstructive surgery undertaken
 • Temporary abdominal closure

49.  Temporary closure of the open abdomen is best
accomplished by :
• VAC Dressing.
• Fascial tensioning.
 • Abdominal closure is best accomplished by hospital
day 8 to reduce morbidity.

52. Liver
 • peri-hepatic packing- anteroposterior plane ,
hepatorenal space
 • Pringles manouvre
 • transfer to angiography suite immediately after the
operation to identify any ongoing arterial haemorrhage
which may be controlled with selective angiographic
embolization.

55. Spleen
 Splenectomy
 Minor splenic injuries- direct suture techniques

57. GIT
 • control of haemorrhage
 • prevention of further contamination by controlling spillage
of gut contents.
 • Small gastrotomies or enterotomies rapidly closed
primarily with a single layer continuous suture.
 • colonic injuries, multiple small bowel lesions-- resect non-
viable bowel, close the ends, relook at 2nd procedure.
 • linear stapler
 • Ileostomy, colostomy avoided if abdomen to be left open

58. Pancreas
 Rarely requires or allows definitive surgery
 • Minor injuries not involving the duct (AAST I,II,IV)
require no treatment.
 • Distal Injury(Left of SMV- AAST III) with extensive tissue
destruction including pancreatic duct-- rapid distal
pancreatectomy.
 • Massive injuries to the pacreaticoduodenal complex
(AAST V) - debridement only.
 • Duodenal injuries- single suture/ temporarily close
ends(major)

59. Vasculature
 Arterial
 “Ligatable” arteries:
• Common and external carotid
• Subclavian, axillary
• Internal iliac
• Celiac axis, IMA
• ICA ligation 10-20% risk of CVA
• EIA, CFA, SFA ligation >> high risk limb ischemia
• SMA: gut necrosis
 Venous
• Almost all veins (including the IVC) can be ligated when
needed

60. Abdomen Vasculature
 Full exposure of the injuries.
• Kocher maneuver
• Cattell-Braasch
• Mattox
 Aorta
• direct suture
• transposition PTFE graft
• Intravascular shunts

61. Kocher Maneuver
 The peritoneum is incised at the right edge of the
duodenum, and the duodenum and the head of pancreas
are reflected to the opposite direction, i.e. to the left, to
expose structures in the retroperitoneum behind
the duodenum and pancreas; for example to
control hemorrhage from the inferior vena cava or aorta,
or to facilitate removal of a pancreatic tumour.

63. Emil Theodor Kocher
 1841-1917
 Nobel Prize in Physiology
or Medicine for thyroid disease
work(1909)

64. Kocher in surgery
 Kocher's forceps
 Kocher's point
 Kocher manoeuvre for retroperitoneal exposure
 Kocher manoeuvre for shoulder dislocation
 Kocher–Debre–Semelaigne syndrome: hypothyroidism in infancy
or childhood characterised by lower extremity or generalized
muscular hypertrophy, myxoedema, short stature and cretinism
 Kocher's collar incision -- is used in thyroid surgery
 Kocher's subcostal incision -- Cholecystectomy
 Kocher's sign -- eyelid phenomenon in hyperthyroidism and
Basedow's disease
Wikipaedia

65. Cattell-Braasch- Right medial
Visceral rotation
 Medial visceral rotation of the right-sided organs to bring
them into the midline. It can be regarded as an extension of
a Kocher's manoeuvre; where as a Kocher's lifts
the duodenum off the retroperitoneum, in a Cattell-Brasch
manoeuvre, dissection is continued down the right-
sided white line of Toldt and then across the small bowel
mesenteric root.

67. Mattox- Left medial Visceral
rotation

68. Retroperitoneal Zones approach

69. Zone I
 Mandatory exploration
 Supramesocolic: Prox. control: Supraceliac aorta
 Inframesocolic: Prox. control: Infrarenal aorta / IVC
Zone II , III
 Selective exploration (if penetrating)
 Leave alone if from blunt trauma
 Opening a pelvic retroperitoneal haematoma in the
presence of a pelvic fracture is almost universally fatal!!

70. Ortopaedics
 Control Bleeding
 Manage Soft tissues
 Spanning Ex. Fixator
 Antibiotic Pouch
 Vacuum Dressings

71. Complications (more less than
tradition surgery)
 Abdominal compartment syndrome(ACS)
 General copmlications:
Sepsis
Dehiscence of wounds
Enterocutaneous fistula
ICU-related infections
skin complications

72. ACS
 Recognised by -- tensely distended abdomen, elevated peak
airway pressures, inadequate ventilation, hypoxia and
oliguria or anuria.
 The clinical diagnosis can be recognised by intra-abdominal
pressure over 35 cm water is diagnostic

73. The management is release.
 Sudden release ACS leads to :
 • ischaemia-reperfusion injury-- acidosis, vasodilatation,
cardiac dysfunction and cardiac arrest.
 • Prior, pre-load with crystalloid solution, Mannitol and
vasodilators such as dobutamine

74. Case no. 1 presentation at
sohag university hospitals
 Male , 32 yrs old with RTA and dragging came to ED of
Sohag University hospitals 2017, shocked,GCS +/- 15
with degloved anterior abdominal wall with pedicle on rt
side, exposed both testicles and degloved root of penis
and rt thigh
 Also he had complete disruption and laceration of the
anal canal all around
 Resuscitation done with wash of the wound and
cleaning.
 FAST…… rim of collection HB– 8 blood grouping
and cross matching done
 What was the Ideal decision ?
 What had been done and its fate ?

77. Bad / good decision?
 The fate talks

78. Case no. 2
 Male , 41 yrs old , came to ED 2014 , after RTA after 4
hours delay in the transportation by 1ry centers in
Sohag , he was shocked , GCS +/- 15 , abdominal
examination…. Tender ,tense with shifting dullness
 Resuscitation done
 HB--- 8
 FAST--- mild to moderate collection , splenic laceration &
aspiration blood
 The pt transported to OR and anasthesia team refused to
anasthetize till blood is available.
 Blood group B+
 The blood does not cross match many times for about
1.5 hr
 The pt deteriorated in the op. room and finally
anasthesia team was forced by pt state to anasthetize
 But , it was too late.
 What was the ideal ?

79. Case no. 3
 Male 23 yrs old , MCA, presnted to the ED with shock , scalp
lacerations ,multiple facial abrasions and edema , GCS +/- 9
 ICU admission and resuscitation done
 FAST---- free HB-- 7.5
 CT brain…. Large Extradural hematoma
 3D CT face --- panfacial fracture (mandible- nose - maxilla)
what
 Ideal
 Real
 Fate

81. Home message
 Management of disasters requires prompt thinking and
aggressive surgical intervention.
 Delay in the decision to perform DC contributes to a very
high morbidity and mortality.
 DCS is an important part of the management of the
multiply injured patient and should be achieved before
metabolic dangers occur.
 Patients who had death rate in ISS≥90%, survived after
DC protocols application.
 Give your patient the chance to fight another day alive.

82. The modern operation is safe for the
patient.
The modern surgeon must
make the patient safe for the modern
operation“
- Lord Moynihan (1865-1936)

83. Recommendations
 Good and rapid transportation system must be available
 Fund for health care must be at basic level in the policy of the
country
 Well qualified surgeons are available and this is by
continuous learning and training
 Trauma protocols should be applied strictly
 The general surgery department protocols for trauma and in
general should be changed
 Law should be modified (traffic – murder – problem solving –
weapons restriction )

85. To avoid sins not mistakes

88. ‫قال‬ ‫ما‬ ‫وأجمل‬
َ‫ي‬ ِ‫ل‬‫ـا‬َ‫ب‬ ِ‫الج‬ َ‫د‬‫و‬ُ‫ع‬ُ‫ص‬ ّ‫ب‬ ِ‫ح‬ُ‫ي‬ ‫ال‬ ْ‫ن‬َ‫م‬َ‫و‬ِ‫ر‬ْ‫ه‬َّ‫د‬‫ال‬ َ‫د‬َ‫ب‬َ‫أ‬ ْ‫ش‬ِ‫ع‬
َ‫ن‬ْ‫ي‬َ‫ب‬‫ـر‬َ‫ف‬ُ‫ح‬‫ال‬
ْ‫ت‬َّ‫ج‬َ‫ع‬َ‫ف‬َّ‫ش‬‫ال‬ ُ‫ء‬‫ا‬َ‫م‬ِ‫د‬ ‫ي‬ِ‫ب‬ْ‫ل‬َ‫ق‬ِ‫ب‬ْ‫ت‬َّ‫ج‬َ‫ض‬َ‫و‬ ِ‫ب‬‫ـا‬َ‫ب‬
‫ر‬َ‫خ‬ُ‫أ‬ ٌ‫ح‬‫ا‬َ‫ي‬ ِ‫ر‬ ‫ي‬ ِ‫ْر‬‫د‬َ‫ص‬ِ‫ب‬
‫ال‬ ِ‫ْف‬‫ص‬َ‫ق‬ِ‫ل‬ ‫ي‬ِ‫غ‬ْ‫ص‬ُ‫أ‬ ،ُ‫ت‬ْ‫ق‬َ‫ر‬ْ‫ط‬َ‫أ‬َ‫و‬ِ‫ف‬ْ‫َز‬‫ع‬َ‫و‬ ِ‫د‬‫ُو‬‫ع‬ُّ‫ر‬
‫ـر‬َ‫ط‬َ‫م‬‫ال‬ ِ‫ع‬ْ‫ق‬َ‫و‬َ‫و‬ ‫اح‬َ‫ي‬ِّ‫الر‬
ُ‫ض‬ْ‫ر‬َ‫أل‬‫ا‬ َ‫ي‬ِ‫ل‬ ْ‫ت‬َ‫ل‬‫ا‬َ‫ق‬َ‫و‬-َ‫أ‬َ‫س‬ ‫ا‬َّ‫م‬َ‫ل‬ُ‫ت‬ْ‫ل‬" :ْ‫ل‬َ‫ه‬ ُّ‫م‬ُ‫أ‬ ‫ـا‬َ‫ي‬َ‫أ‬
‫َر؟‬‫ش‬َ‫ب‬‫ال‬ َ‫ين‬ِ‫ه‬َ‫ر‬ْ‫ك‬َ‫ت‬"
"ُ‫م‬ُّ‫ط‬‫ال‬ َ‫ل‬ْ‫ه‬َ‫أ‬ ِ‫اس‬َّ‫ن‬‫ال‬ ‫في‬ ُ‫ك‬ ِ‫ار‬َ‫ب‬ُ‫أ‬ُّ‫ذ‬‫ـ‬ِ‫ل‬َ‫ت‬ْ‫س‬َ‫ي‬ ْ‫ن‬َ‫م‬َ‫و‬ ِ‫وح‬
‫ـر‬َ‫ط‬َ‫خ‬‫ال‬ َ‫ُوب‬‫ك‬ُ‫ر‬
ُ‫ن‬َ‫ع‬ْ‫ل‬َ‫وأ‬َ‫ـان‬َ‫م‬َّ‫الز‬ ‫ي‬ِ‫ش‬‫ا‬َ‫م‬ُ‫ي‬ ‫ال‬ ْ‫ن‬َ‫م‬‫ـ‬ْ‫ي‬َ‫ع‬‫ال‬ِ‫ب‬ ُ‫ع‬َ‫ن‬ْ‫ق‬َ‫ي‬َ‫و‬ِ‫ش‬
‫ر‬َ‫ج‬َ‫ح‬‫ال‬ ِ‫ش‬ْ‫ي‬َ‫ع‬
َ‫هو‬َ‫ي‬َ‫ح‬‫ال‬ ُّ‫ـب‬ ِ‫ح‬ُ‫ي‬ ، ٌّ‫ي‬َ‫ح‬ ُ‫ن‬ ْ‫َو‬‫ك‬‫ال‬َ‫م‬ْ‫ل‬‫ا‬ ُ‫ر‬ِ‫ق‬َ‫ت‬ْ‫َح‬‫ي‬َ‫و‬ َ‫ة‬‫ا‬َ‫ْت‬‫ي‬
‫ر‬ُ‫ب‬‫َـ‬‫ك‬ ‫ا‬َ‫م‬ْ‫ه‬َ‫م‬
‫ال‬َ‫ف‬ُّ‫ط‬‫ال‬ َ‫ْت‬‫ي‬َ‫م‬ ُ‫ن‬ُ‫ض‬ْ‫َح‬‫ي‬ ُ‫ق‬ْ‫ف‬ُ‫أل‬‫ا‬َ‫ي‬ ُ‫ل‬ْ‫ح‬َّ‫ن‬‫ال‬ ‫ال‬َ‫و‬ ِ‫ور‬ُ‫ي‬ُ‫م‬ِ‫ث‬ْ‫ل‬
‫ــر‬َ‫ه‬َّ‫الز‬ َ‫ْت‬‫ي‬َ‫م‬
َ‫ة‬‫ـا‬َ‫ي‬َ‫ح‬ْ‫ل‬‫ا‬ َ‫د‬‫ا‬َ‫أر‬ ‫ا‬َ‫م‬ ْ‫و‬َ‫ي‬ ُ‫ب‬ْ‫ع‬ّ‫ش‬‫ال‬ ‫إذا‬ْ‫أن‬ َّ‫د‬ُ‫ب‬ ‫ال‬َ‫ف‬
َ‫يب‬ ِ‫ج‬َ‫ت‬ْ‫س‬َ‫ي‬‫َر‬‫د‬‫ـ‬َ‫ق‬‫ال‬
‫ــ‬ِ‫ل‬َ‫ج‬ْ‫ن‬َ‫ي‬ ْ‫أن‬ ِ‫ل‬ْ‫ـ‬‫ي‬َّ‫ل‬ِ‫ل‬ َّ‫د‬‫ـ‬ُ‫ب‬ ‫ال‬َ‫و‬ْ‫ن‬َ‫أ‬ ِ‫د‬ْ‫ي‬َ‫ق‬‫لل‬ َّ‫د‬ُ‫ب‬ ‫ال‬َ‫و‬ ‫ي‬
‫ـر‬ِ‫س‬َ‫ك‬ْ‫ن‬‫ـ‬َ‫ي‬
ْ‫ن‬َ‫م‬َ‫و‬َ‫ح‬ْ‫ل‬‫ا‬ ُ‫ق‬ ْ‫َو‬‫ش‬ ُ‫ه‬ْ‫ق‬ِ‫ن‬‫ا‬َ‫ع‬ُ‫ي‬ ْ‫م‬َ‫ل‬‫في‬ َ‫ـر‬َّ‫خ‬َ‫ب‬َ‫ت‬ ِ‫ة‬‫ـا‬َ‫ي‬
‫ـا‬َ‫ه‬ِّ‫و‬َ‫ج‬‫ـر‬َ‫ث‬َ‫د‬ْ‫ن‬‫ا‬َ‫و‬
‫ا‬َ‫ه‬‫ـ‬ُ‫ح‬‫و‬ُ‫ر‬ ‫نـي‬َ‫ث‬ّ‫د‬َ‫ح‬َ‫و‬ ُ‫ات‬َ‫ن‬ِ‫ئ‬‫َا‬‫ك‬‫ال‬ َ‫ي‬‫ـ‬ِ‫ل‬ ْ‫ـت‬َ‫ل‬‫ا‬َ‫ق‬ َ‫ك‬ِ‫ل‬‫َذ‬‫ك‬
‫ر‬ِ‫ت‬َ‫ت‬ْ‫س‬ُ‫م‬‫ال‬
ِ‫ت‬َ‫م‬َ‫د‬‫َم‬‫د‬َ‫و‬ِ‫اج‬َ‫ج‬ِ‫ف‬‫ال‬ َ‫ن‬ْ‫ي‬َ‫ب‬ ُ‫ح‬‫ي‬ِّ‫الر‬‫ال‬َ‫ب‬ ِ‫الج‬ َ‫ق‬ ْ‫و‬َ‫ف‬َ‫و‬
‫ر‬َ‫ج‬َّ‫ش‬‫ال‬ َ‫ت‬ْ‫ح‬َ‫ت‬َ‫و‬
‫ا‬َ‫ذ‬‫إ‬ْ‫ب‬ِ‫ك‬َ‫ر‬ ٍ‫ة‬َ‫ي‬‫ـا‬َ‫غ‬ ‫ـى‬ِ‫ل‬‫إ‬ ُ‫ـت‬ْ‫ح‬َ‫م‬َ‫ط‬ ‫ا‬َ‫م‬‫ى‬َ‫ن‬ُ‫م‬ْ‫ل‬‫ا‬ ُ‫ت‬
‫ر‬َ‫ذ‬َ‫ح‬‫ال‬ ُ‫يت‬ِ‫س‬َ‫ن‬َ‫و‬
ْ‫م‬َ‫ل‬َ‫و‬ِ‫ب‬‫ـ‬َ‫ه‬َّ‫ل‬‫ال‬ َ‫ـة‬َّ‫ب‬ُ‫ك‬ ‫ال‬َ‫و‬ ِ‫ب‬‫ـا‬َ‫ع‬ِّ‫ش‬‫ال‬ َ‫ُـور‬‫ع‬ُ‫و‬ ْ‫ب‬َّ‫ن‬َ‫ج‬َ‫ت‬َ‫أ‬
‫ـر‬ِ‫ع‬َ‫ت‬ْ‫س‬ُ‫م‬‫ال‬

89. ِ‫ل‬‫ا‬َ‫م‬َ‫ج‬‫ال‬ ُ‫يب‬ ِ‫َر‬‫غ‬ ٌ‫ح‬‫و‬ُ‫ر‬ َ‫ف‬ َ‫ر‬ْ‫ف‬ َ‫ر‬ َ‫و‬ْ‫ن‬ِ‫م‬ ٍ‫ة‬‫ـ‬َ‫ح‬ِ‫ن‬ْ‫ج‬َ‫أ‬ِ‫ب‬
ِ‫اء‬َ‫ي‬ ِ‫ض‬‫ـر‬َ‫م‬َ‫ق‬ْ‫ال‬
َ‫ق‬ُ‫م‬ْ‫ال‬ ِ‫ة‬‫ا‬َ‫ي‬َ‫ح‬ْ‫ال‬ ُ‫د‬‫ي‬ِ‫ش‬َ‫ن‬ َّ‫ن‬ َ‫ر‬ َ‫و‬ِ‫ل‬‫ا‬َ‫ح‬ ٍ‫ل‬‫ـ‬َ‫ك‬ْ‫ي‬َ‫ه‬ ‫في‬ ِ‫َّس‬‫د‬‫ـ‬ٍ‫م‬
‫ر‬ ِ‫ـح‬ُ‫س‬ ْ‫د‬َ‫ق‬
َ‫ن‬َ‫ل‬ْ‫ع‬َ‫أ‬ َ‫و‬ُّ‫الط‬ َّ‫ن‬َ‫أ‬ ِ‫ن‬ ْ‫و‬َ‫ك‬ْ‫ال‬ ‫في‬َ‫ي‬َ‫ح‬ْ‫ال‬ ُ‫يب‬ِ‫ه‬َ‫ل‬ َ‫ح‬‫و‬ُ‫م‬ِ‫ة‬‫ـا‬
ُ‫ح‬‫و‬ُ‫ر‬ َ‫و‬‫ـر‬َ‫ف‬َّ‫الظ‬
ُ‫ف‬ُّ‫ن‬‫ال‬ ِ‫ة‬‫ا‬َ‫ي‬َ‫ح‬ْ‫ل‬ِ‫ل‬ ْ‫ت‬َ‫ح‬َ‫م‬َ‫ط‬ ‫ا‬َ‫ذ‬ِ‫إ‬ْ‫ن‬َ‫أ‬ َّ‫د‬ُ‫ب‬ ‫ال‬َ‫ف‬ ُ‫وس‬
ْ‫ر‬َ‫د‬‫ـ‬َ‫ق‬ْ‫ال‬ َ‫يب‬ ِ‫ج‬َ‫ت‬ْ‫س‬َ‫ي‬

90. References
 Schreiber, M.A., 2004. Damage control surgery. Critical care
clinics, 20(1), pp.101-118.
 Hoey, B.A. and Schwab, C.W., 2002. Damage control
surgery. Scandinavian journal of surgery, 91(1), pp.92-103.
 Morris, D.S., 2015. Damage Control Surgery. Encyclopedia
of Trauma Care, pp.414-415.
 Surface ship survivability, Naval war publication 3-20.31,
Washington, DC. Department of defense; 1996
 Weber, D.G., Bendinelli, C. and Balogh, Z.J., 2014. Damage
control surgery for abdominal emergencies. British Journal of
Surgery, 101(1), pp.e109-e118.
 Roberts, D.J., Bobrovitz, N., Zygun, D.A., Ball, C.G.,
Kirkpatrick, A.W., Faris, P.D. and Stelfox, H.T., 2015.
Indications for use of damage control surgery and damage
control interventions in civilian trauma patients: a scoping
review. Journal of trauma and acute care surgery, 78(6),
pp.1187-1196.

91.  Cannon, J.W., Khan, M.A., Raja, A.S., Cohen, M.J., Como,
J.J., Cotton, B.A., Dubose, J.J., Fox, E.E., Inaba, K.,
Rodriguez, C.J. and Holcomb, J.B., 2017. Damage control
resuscitation in patients with severe traumatic hemorrhage: a
practice management guideline from the Eastern Association
for the Surgery of Trauma. Journal of Trauma and Acute Care
Surgery, 82(3), pp.605-617.
 Garner, J. and Ivatury, R.R., 2018. The Open Abdomen in
Damage Control Surgery. In Damage Control in Trauma
Care(pp. 263-275). Springer, Cham.
 Polk, T.M., Martin, M.J. and Barbosa, R.R., 2018. Damage
Control Surgery in the Blast-Injured Patient. In Managing
Dismounted Complex Blast Injuries in Military & Civilian
Settings (pp. 57-76). Springer, Cham.

92. Thank you all