INTRODUCTION — Severely injured patients often do not have the physiologic reserve to tolerate definitive repair. The term "damage control" was borrowed from the United States Navy to refer to special teams that are responsible for keeping a severely damaged ship afloat until it can be returned to port for definitive repair. In a similar manner, damage control surgery serves to attend to immediately life-threatening conditions (keeping the patient afloat), while definitive management of these and other non-life-threatening injuries are delayed until after appropriate resuscitation. Although damage control surgery and resuscitation was initially described following abdominal injury, the basic principle has been extended to all aspects of trauma care.
The principles of damage control and resuscitation, as well as the damage control sequence, are reviewed here. The surgical management of specific injuries is discussed in detail in separate topic reviews.
PRINCIPLES OF DAMAGE CONTROL
Background and terminology — Severely injured patients may require operative intervention to treat immediately life-threatening conditions but often do not have sufficient physiologic reserve to tolerate a prolonged operation. What would be regarded today as damage control surgery was first reported in 1983 as a laparotomy that was stopped due to excessive bleeding following bowel resection . The intestines were left in discontinuity; the abdomen was packed open, and, after resuscitation in the intensive care unit, the patient was later returned to the operating room for definitive intestinal repair and abdominal closure. The term "damage control surgery" was later used to describe abbreviated laparotomy in the context of trauma . The principles of damage control have since extended to all aspects of trauma care.
Phases of care — The damage control approach can be broken down into distinct phases summarized below and discussed in the next sections more fully (figure 1) . Damage control resuscitation principles should be applied throughout all phases of damage control.
●Phase 0 – Presurgery damage control involves rapid transport and rapid triage for treatment (eg, operating room, interventional suite). (See 'Presurgery damage control' below.)
●Phase 1 – Damage control surgery is aimed at arresting hemorrhage, limiting contamination, and maintaining optimal blood flow to vital organs and the extremities. Operative time is limited to minimize further hypothermia, coagulopathy, and acidemia. (See 'Damage control surgery' below.)
●Phase 2 – Resuscitation in the intensive care unit involves intravenous fluid therapy to establish euvolemia using a balanced approach and warming the patient. These measures, along with appropriate airway and ventilatory management, will help to normalize tissue oxygen delivery and resolve acidosis and coagulopathy. (See 'Resuscitation' below.)
●Phase 3 – Definitive repair of injuries temporized during damage control surgery may require a staged approach to address all injuries. The timing of definitive repair is determined by the patient's physiologic status. (See 'Definitive repair' below.)
●Phase 4 – Closure of abdominal or other soft tissue wounds often requires complex reconstructive surgery, which is delayed until after complete recovery from the associated injuries. (See 'Delayed abdominal/soft tissue closure' below.)
Efficacy — Damage control surgery has not been validated prospectively. However, outcomes using a damage control approach compared with historical controls have shown significant reductions in morbidity and mortality . As such, any study withholding such an approach would be deemed unethical .
In the earliest report involving 22 patients with major vascular injury or two or more visceral injuries, mortality was reduced 66 percent using damage control techniques compared with standard techniques for the era (77 versus 11 percent) .
INDICATIONS — Damage control should be initiated in severely injured patients with multisystem trauma, but there are no absolute, evidence-based prediction models of who would benefit.
A systematic review identified various indications used for damage control, and the validity of these indications was assessed by a panel of surgeons . The indications most commonly reported and highly rated by the panel included:
●Severe degree of physiologic insult
•Hypothermia (temperature <34°C)
•Clinical or laboratory evidence of coagulopathy in the preoperative or intraoperative settings (prothrombin time [PT] and partial thromboplastin time [PTT] >1.5 times normal, absence of visible blood clots during operation or diffuse oozing from injured tissues)
•Intraoperative evidence of persistent cellular shock (pH <7.2, base deficit >15 mol/L, lactate >5 mmol/L, O2 consumption index <100 mL/min/m2)
•Development of intraoperative ventricular arrhythmias
●Need for internal packing to control hemorrhage
●Large-volume resuscitation required
•A large volume of packed red blood cells (median >10 U).
•A combined large volume of packed red blood cells, other blood products, and crystalloids (median >12 L) administered preoperatively or across the pre- and intraoperative settings.
•It is important to note that leaving the abdominal wall open following a large volume resuscitation was a common occurrence in the early 2000s, even in the absence of other damage control indications or maneuvers. However, with later attention focused on a balanced and goal-directed resuscitation in trauma and critical care, over-resuscitation has reduced.
●Injury pattern identified during surgery
•Difficult to access major venous injury (intrahepatic, retrohepatic, retroperitoneal, or pelvic)
•Major liver or combined pancreaticoduodenal injury with hemodynamic instability in the operating room
•Combined pancreaticoduodenal injury with massive hemorrhage from the head of the pancreas
•Devascularization or massive disruption of the duodenum, pancreas, or pancreaticoduodenal complex with involvement of the ampulla/proximal pancreatic duct and/or distal common bile duct
●Need for staged abdominal or thoracic wall reconstruction
•Inability to close the abdominal or thoracic wall without tension because of visceral edema
•Signs of an abdominal or thoracic compartment syndrome develop during attempted abdominal or thoracic wall closure
•Need to reassess the extent of bowel viability after a period of further resuscitation in the intensive care unit
PRESURGERY DAMAGE CONTROL — Damage control begins in the field and continues during transport and initial evaluation of the patient in the emergency department.
Early recognition of the need for a damage control approach minimizes wasted time in the emergency department and limits physiologic strain. Initiating a damage control approach is based not only upon the type of traumatic injury but also includes the physiologic response to the injury [7-9]. Prior to arrival at the hospital, the trauma patient's physiologic response can be determined by vital signs and mental status. Recognition of severe physiologic abnormalities, especially in the face of penetrating trauma, should prompt prehospital personnel to abort all but lifesaving maneuvers to expedite patient delivery to the hospital environment for definitive care .
During transport to the trauma center, the best strategy for minimizing mortality appears to be to perform only those interventions that are absolutely necessary to control hemorrhage and promote gas exchange [10-12]. Even taking the time to start intravenous therapy may result in an unnecessary delay to definitive care . An exception may be in the rural setting where transport times to definitive care may be prolonged. Intubation, in particular, protects the airway and ensures adequate oxygenation and ventilation; however, rates of successful endotracheal intubation by prehospital personnel in the rural setting are lower compared with the urban setting . In addition, intubation in severely hypovolemic patients may worsen hemodynamic instability and result in cardiac arrest . As such, the safest approach may be to expeditiously transfer a patient to a trauma center following injury, regardless of the rural versus urban setting in which the event occurs. Other rescue airway options exist and can be carried out expeditiously if prehospital providers are familiar with their use.
In the emergency department, the nature and extent of injuries can be rapidly determined, and physical examination (vital signs, temperature) and laboratory studies (eg, base deficit, lactate, coagulation parameters) help assess the magnitude of physiologic derangement. Any patient having undergone a resuscitative thoracotomy should be immediately placed into a damage control algorithm secondary to the severe physiologic insult. Damage control resuscitation, which includes a balanced blood product resuscitation, should begin as early as possible. (See "Initial management of trauma in adults" and "Approach to shock in the adult trauma patient".)
DAMAGE CONTROL SURGERY — The goals of damage control surgery are to first arrest hemorrhage and then to limit contamination, such as from gastrointestinal tract injury. Implicit in this philosophy is the need to maintain blood flow to the vital organs and extremities, using temporary shunts if necessary. This holds true regardless of location, as damage control methodologies can be instituted in the head, chest, abdomen, and extremities. Life-threatening injuries to the head, neck, chest, or abdomen take precedence over extremity injuries, which, in spite of best efforts, may not be salvaged. (See "Severe upper extremity injury in the adult patient" and "Severe lower extremity injury in the adult patient".)
Damage control surgery should be performed in a diligent and expeditious fashion to minimize additional physiologic insult. Operative times should be approximately 90 minutes or less, as prolonged operation will cause or exacerbate existing hypothermia, coagulopathy, and acidemia, which increase morbidity and mortality . Identified injuries are temporized, and definitive repair is deferred until the patient has stabilized. (See 'Resuscitation' below and 'Definitive repair' below.)
Although damage control was initially described for laparotomy in patients with abdominal injury, its principles have extended to all surgical disciplines.
●Damage control laparotomy focuses on controlling hemorrhage and contamination as well as leaving the abdomen open to prevent abdominal compartment syndrome. In a similar manner, although less common, damage control thoracotomy/sternotomy would refer to leaving the sternum or hemithorax open to prevent cardiac tamponade in cases where the heart is significantly distended or edematous, and to control hemorrhage from the pleura, respectively. (See 'Damage control laparotomy' below and 'Others' below.)
●Damage control of extremity injuries often requires cooperation of orthopedic and vascular surgery specialists. Damage control orthopedic surgery quickly places external fixation devices in patients who are too unstable to undergo definitive internal stabilization or who have contaminated wounds [17,18]. Damage control vascular surgery places temporary shunts into injured vessels to maintain blood flow (picture 1), rather than ligation or definitive revascularization, and liberally uses fasciotomy to prevent extremity compartment syndromes. (See 'Extremity stabilization' below.)
●Principles of damage control surgery can be applied to other surgical disciplines as well, including neurosurgery and urology. As an example, decompressive craniectomy may be used to manage refractory intracranial hypertension. In this context, damage control refers more to limiting operative time, potential blood loss, and propensity for hypothermia to develop in order to allow for resuscitation and reconstitution of normal physiology in the intensive care unit setting . (See 'Others' below.)
Damage control laparotomy — The fundamental strategy of damage control laparotomy, with the following priority, is to control hemorrhage, control contamination, and provide temporary abdominal closure to prevent abdominal compartment syndrome and facilitate subsequent procedures once the patient has been resuscitated [20-22].
Exploratory laparotomy should be performed via a midline incision because it is rapid and allows for complete observation and mobilization of intraperitoneal and/or retroperitoneal structures. The skin, subcutaneous tissue, and midline fascia (linea alba) are incised, leaving the peritoneum intact. Then, anesthesia personnel are informed and should be prepared for blood loss, which may occur once the tamponade of the closed abdomen is released during the opening of the peritoneum.
●Packing and exploration – Immediately after opening the peritoneum, the abdomen is packed in all four quadrants. Laparotomy pads are first packed in quadrants where bleeding appears most significant. To explore the abdomen, the abdominal packs are then deliberately removed in reverse order, and active bleeding is controlled as it is encountered before addressing any gastrointestinal contamination.
●Control hemorrhage – In general, hemorrhage is controlled by resecting severely damaged nonessential organs (eg, spleen) (picture 2), leaving severely damaged essential organs packed (most commonly the liver), and ligating or shunting transected intra-abdominal vessels [23,24]. Intra-abdominal blood vessels that are not end vessels can be ligated. However, essential vessels should be shunted rather than repaired (picture 3) when rapid restoration of perfusion is needed so that other injuries can be addressed; restoration of physiology can be obtained in a more timely fashion . This approach maintains perfusion while also controlling hemorrhage (table 1). (See "Abdominal vascular injury" and "Overview of blunt and penetrating thoracic vascular injury in adults" and "Surgical management of splenic injury in the adult trauma patient" and "Surgical techniques for managing hepatic injury".)
●Control contamination – Control of contamination is obtained by sealing or resecting perforated hollow viscera. Gastric injuries can be oversewn quickly or stapled; less severe, partial- or full-thickness small and large bowel injuries can be repaired primarily, if this can be performed expeditiously; and more severe, small or large bowel injuries are most commonly resected (table 2). If resection has been performed, the bowel is left in discontinuity, rather than being anastomosed, thereby hastening the operation, and also avoiding the potential postoperative complication of anastomotic dehiscence. Performing an anastomosis in the face of diminished perfusion or multiple transfusions increases the risk of gastrointestinal anastomotic dehiscence [25,26]. However, where physiology is normalized, the risk of anastomotic dehiscence during the index operation is not significantly higher compared with repair at a later stage in the damage control sequence (ie, phase 3) [27-30]. (See "Traumatic gastrointestinal injury in the adult patient", section on 'Management of intestinal injuries' and "Management of the open abdomen in adults", section on 'Ostomy interference'.)
●Temporary abdominal closure – Temporary abdominal closure can be achieved in a variety of ways, which are discussed in detail separately. Negative pressure dressings (picture 4) are a commonly used method to provide temporary abdominal closure following damage control laparotomy because the dressing allows peritoneal fluid efflux, which can be accounted for in fluid resuscitation, improves the ability to bring the fascial edges back together, and facilitates second-look laparotomy . A second-look laparotomy may be needed if the patient remains severely hemodynamically unstable or hypothermic, where the possibility of a missed injury causing ongoing hemorrhage or contamination needs to be considered. (See "Management of the open abdomen in adults".)
Damage control thoracotomy/sternotomy — Similar to abdominal damage control, when physiology warrants damage control methodology, chest injuries can be managed and the chest/sternum temporarily closed using similar techniques as described below for the abdomen. This will similarly allow for fluid effluent and a rapid second look if necessary. (See "Resuscitative thoracotomy: Technique", section on 'Damage control' and "Resuscitative thoracotomy: Technique", section on 'Definitive management'.)
Extremity stabilization — When a patient's physiology does not lend itself to a prolonged intervention to manage pelvic or extremity injuries, open wounds are present precluding internal fixation, or complex injuries are present (eg, open fracture with vascular compromise), damage control orthopedic and vascular procedures can be used. These include pelvic or extremity splinting, traction, or external pelvic or extremity fixation (picture 5), with or without vascular shunting to manage associated vascular injuries. (See "Surgical management of severe lower extremity injury", section on 'Primary fracture management' and "Surgical management of severe upper extremity injury", section on 'Primary fracture management'.)
Damage control orthopedic surgery focuses on reducing and stabilizing the fractured segments, which helps to control perifracture bleeding and reduces the risk of injury to surrounding nerves and vessels. In selected instances, external fixation may also serve as definitive therapy of a fracture, particularly those involving the tibia [32-34]. But in general, definitive repair is delayed until physiology has returned to normal, wounds in the area of open fractures are clean, and subsequent procedures are less likely to become infected. (See 'Definitive repair' below.)
There is a low threshold to perform extremity fasciotomy following reperfusion of an ischemic limb. (See "Lower extremity fasciotomy techniques" and "Patient management following extremity fasciotomy".)
●Decompressive craniectomy has been used to manage intracranial pressure that cannot be adequately controlled using medical therapy, or following evacuation of an intracranial hematoma (eg, epidural or subdural hematoma) where significant brain edema is expected or already present . By allowing the edematous brain to expand beyond the usual confines of the cranium, decompressive craniectomy dissipates intracranial pressure and reduces the risk of stroke and uncal herniation. The skull flap is left off to allow the brain to swell, and downstream reconstructive efforts, such as definitive cranioplasty, occur two to three months following operation. A single trial of decompressive craniectomy following traumatic brain injury failed to show a mortality benefit . However, this study has been criticized regarding its inclusion criteria . Smaller studies on mortality outcomes following neurologic injury suggest a benefit if the procedure is performed to evacuate hematoma, or to allow the edematous brain to expand [37,38].
●During damage control laparotomy, unilateral nephrectomy may be required to control hemorrhage from an injured kidney if a normal-feeling kidney is palpated on the contralateral side. In the rare event that both kidneys are injured, salvage should be attempted within reason. In cases of ureteral injury noted in hemodynamically unstable patients, the ureter can be externalized through a separate incision and sutured to the skin, akin to a "stoma," or a stent can be placed into the ureter and the stent can be externalized as a conduit. When pelvic fractures can cause distraction defects in the posterior urethra and a urethral catheter cannot be placed across the defect, damage control involves placement of a suprapubic drainage catheter. Definitive urethroplasty is delayed three to six months later. (See "Overview of the diagnosis and initial management of traumatic retroperitoneal injury" and "Severe pelvic fracture in the adult trauma patient" and "Strictures of the adult male urethra".)
RESUSCITATION — Damage control resuscitation principles begin in the prehospital phase or emergency department phase of care and should be applied throughout all phases of damage control. The goals of care in the intensive care unit are to continue fluid resuscitation, warm the patient, and obtain any further testing or imaging that may be needed to better define the full extent of injuries. These measures, along with appropriate airway and ventilatory management, will help to normalize tissue oxygen delivery and resolve acidosis and coagulopathy.
Severely injured patients are frequently coagulopathic, which complicates ongoing resuscitation. Recognition and management of acute coagulopathy associated with trauma is reviewed separately. (See "Coagulopathy in trauma patients".)
Intravenous fluid therapy is administered to achieve euvolemia using a balanced approach. There are few data upon which to base a specific resuscitative strategy for ongoing resuscitation following damage control surgery, but the principles used in early resuscitation have been extrapolated to this postoperative period . (See "Initial management of moderate to severe hemorrhage in the adult trauma patient" and "Approach to shock in the adult trauma patient".)
Studies of severe hemorrhage following injury have demonstrated the survival benefit of a 1:1:1 ratio of plasma, packed red blood cells, and platelets [40-42]. This is largely due to mitigation of the coagulopathy of trauma by the early administration of fresh frozen plasma and platelets [43,44]. Whole blood transfusion during severe hemorrhage is also associated with improved hemostasis and possibly with improved mortality, although the amount of whole blood that needs to be given to achieve these endpoints is not yet known . A single-center study suggested that administration of a four-factor (II, VII, IX, X) prothrombin complex concentrate, in addition to a balanced resuscitation, may be associated with improved hemostasis and survival in massively bleeding, injured patients .
The use of hypertonic saline as a low-volume maintenance fluid has also been investigated. One study suggests that this strategy may minimize total body sodium overload (ie, edema and anasarca) resulting in a higher rate of functional abdominal fascial closure during phase 3 . Currently, 3% saline is the most commonly used for a safe approach to low-volume resuscitation to promote abdominal wall closure . (See "Management of the open abdomen in adults".)
Prevention and/or correction of hypothermia is an imperative component of damage control resuscitation. Hypothermia contributes to the lethal triad of trauma, in conjunction with worsening acidosis and coagulopathy, creating a vicious downward cycle . All fluids entering the patient should be warmed. The environment, ventilator gas, forced air blankets, and water pads should also be warmed . (See "Perioperative temperature management".)
DEFINITIVE REPAIR — Definitive repair of injuries temporized during damage control surgery usually starts 24 to 48 hours following initial injury. The exact timing is determined by the patient's physiologic status. Ideally, normal physiology should be obtained prior to returning to the operating room.
Definitive repair often requires the assistance of other surgical services (eg, plastic surgery) and may require numerous, separate operations, the timing of which needs to be coordinated by the trauma service in conjunction with the anesthesia service and involved consultants.
●Remove packings placed for hemostasis.
●Segments of intestine that are in discontinuity are reanastomosed, or externalized as stomas. (See "Traumatic gastrointestinal injury in the adult patient".)
●Shunts that had been placed as a temporary conduit to maintain blood flow across severely injured arteries or veins are removed and the vessel primarily repaired (when possible), replaced by interposition grafts, and, less commonly, bypassed. When feasible, external fixation devices are internalized, if necessary. (See "Surgical management of severe lower extremity injury".)
●When possible, the abdominal fascia and soft tissue defects are closed. Primary fascial closure may not be possible following laparotomy for definitive repair of intra-abdominal injuries. When this occurs, management of the open abdomen involves continued temporary abdominal closure until staged closure of the fascia, or other coverage, can be performed. (See 'Delayed abdominal/soft tissue closure' below and "Management of the open abdomen in adults".)
DELAYED ABDOMINAL/SOFT TISSUE CLOSURE — The final phase of damage control is only needed when primary fascial closure of the abdominal wall or definitive soft tissue coverage of bone or neurovascular structures cannot be obtained during the definitive repair phase.
●Closure/coverage is delayed until after all contamination is controlled and edema/inflammation has subsided, which may be several weeks for extremity wounds or as long as 10 to 12 months for delayed ventral hernia repair . (See "Surgical reconstruction of the lower extremity" and "Management of the open abdomen in adults" and "Management of ventral hernias" and "Overview of component separation".)
●Cranioplasty following decompressive craniectomy is usually performed six to eight weeks following the initial surgery, once brain edema has fully resolved.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Abdominal compartment syndrome" and "Society guideline links: General issues of trauma management in adults".)
SUMMARY AND RECOMMENDATIONS
●Damage control refers to an operative strategy predicated on immediately treating only life-threatening injuries and purposefully delaying definitive operative repair of injuries until the patient's physiology has returned to normal. The term "damage control resuscitation" refers to the balanced resuscitation used during this period. Although the damage control approach began with the management of abdominal injuries, these principles are standard of care for severe intrathoracic, vascular, orthopedic, and intracranial injuries as well. Morbidity and mortality rates using a damage control approach have been reduced significantly compared with historical controls. (See 'Principles of damage control' above.)
●The damage control approach can be broken down into distinct phases of care (figure 1). These include presurgery rapid transport and triage, damage control surgery, perioperative resuscitation, definitive repair of injuries temporized during damage control surgery, and delayed abdominal/chest closure and/or coverage of soft tissue wounds. (See 'Phases of care' above.)
●Initiating a damage control approach is based not only upon the type of traumatic injury but also includes the physiologic response to the injury. Although there are no absolute, evidence-based models that predict who would benefit most from damage control, in general damage control should be initiated in patients with multisystem trauma, or any injured patient at risk for or who manifests hypothermia, coagulopathy, and/or metabolic acidosis. (See 'Indications' above.)
●The goals of damage control surgery are to first arrest hemorrhage and then to limit contamination. This holds true regardless of the site of injury (ie, intra-abdominal, intrathoracic, intracranial, extremity). To control hemorrhage, nonessential bleeding vessels should be ligated, while essential bleeding vessels should be shunted or rapidly repaired. Leakage from injuries to the gastrointestinal tract, tracheobronchial tree, or urogenital tract are controlled (eg, closure, exteriorization), and the surrounding region should be irrigated. Temporary closure of the abdomen or chest promotes drainage of fluid and allows rapid return to access if needed. Preemptive extremity fasciotomy prevents the negative sequelae of extremity compartment syndrome. (See 'Damage control surgery' above.)
●Perioperative resuscitation aims to achieve euvolemia, normalize tissue oxygen delivery, and resolve acidosis and coagulopathy by appropriate fluid therapy and transfusion (using near-equal amounts of packed red blood cells, plasma, and platelets), warming the patient, and providing appropriate airway and ventilatory management. An evolving body of literature suggests that the addition of whole blood and four-factor (II, VII, IX, X) prothrombin complex concentrate may further benefit and improve hemostasis and possibly mortality in trauma patients who are massively bleeding.
●Damage control resuscitation principles should be applied throughout all phases of damage control. Any further testing or imaging that is needed to better define the full extent of injuries is also obtained. (See 'Resuscitation' above and "Coagulopathy in trauma patients" and "Initial management of trauma in adults".)
●The timing of definitive repair of injuries temporized during damage control surgery is determined by the patient's physiologic status but typically starts 24 to 48 hours after the initial injury. Definitive repair often requires the coordinated care of multiple other surgical services. (See 'Definitive repair' above and "Management of the open abdomen in adults".)
●The final phase of damage control involves closure of the abdominal/chest cavities and/or definitive soft tissue coverage of bone or neurovascular structures that cannot be obtained during the definitive repair phase. (See 'Delayed abdominal/soft tissue closure' above.)
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