Overview of damage control surgery and resuscitation in patients sustaining severe injury

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 is delayed until after appropriate resuscitation. Although damage control surgery and resuscitation were 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 initial management of the trauma patient is reviewed separately.

●(See "Initial evaluation and management of penetrating thoracic trauma in adults".)

●(See "Initial evaluation and management of blunt thoracic trauma in adults".)

●(See "Abdominal gunshot wounds in adults: Initial evaluation and management".)

●(See "Initial evaluation and management of abdominal stab wounds in adults".)

PRINCIPLES OF DAMAGE CONTROL — 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 [1]. What would be regarded today as damage control surgery was first reported in 1983 [2]. The term "damage control surgery" was later used to describe abbreviated laparotomy in the context of trauma that treats only life-threatening injuries, purposefully delaying definitive operative repair until the patient's physiology improved [3]. Using a damage control approach was associated with reduced morbidity and mortality. Although the damage control approach began with the management of abdominal injuries, these principles have been extended and are the standard of care for severe intrathoracic, vascular, orthopedic, and intracranial injuries as well.

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 [4].

Massive resuscitation — Trauma surgeons will frequently use a damage control strategy for any patient requiring activation of a massive transfusion protocol regardless of the number of packed red blood cell units given. This is to account for a 1:1:1 resuscitation where the total number of packed red blood cell units may be less than 10 units but the combined number of components given is approximately 10 units and/or there is an ongoing need for transfusion. Implementation of a massive transfusion protocol is important to mobilize and support access to the required blood products at the bedside.

Massive transfusion is generally defined as providing >10 units of packed red blood cells. But this criterion implies that the patient will survive long enough to actually receive 10 units, so some advocate for a definition that uses the rate of bleeding (eg, >4 u/hr).

Severe physiologic insult — The following clinical parameters suggest a severe degree of physiologic insult, which may be evident upon arrival in the emergency department or develop in the operating room.

●Hypothermia (temperature <34°C)

●Clinical or laboratory evidence of coagulopathy in the preoperative or intraoperative settings (prothrombin time and partial thromboplastin time >1.5 times normal, absence of visible blood clots during operation or diffuse oozing from injured tissues)

●Severe shock (pH <7.2, base deficit >8 to 10 mol/L, lactate >5 mmol/L)

Severe pattern of injury — The mechanism of injury or findings on imaging may suggest that a damage control approach will likely be needed.

●Hemorrhage that is likely to require internal packing for control as may be required for known severe liver injury. (See 'Liver' below.)

●Severe combined organ injuries likely to need a staged approach (eg, multiple bowel injuries, combined chest and abdominal injuries). (See 'Need for staged surgery' below.)

Injury patterns typically identified during surgery that suggest the need for a damage control strategy include the following:

●Difficult to access major venous injury (intrahepatic, retrohepatic, retroperitoneal, or pelvic). (See 'Evaluate the retroperitoneum' below.)

●Major liver injury with hemodynamic instability in the operating room. (See 'Liver' below.)

●Combined pancreaticoduodenal injury with massive hemorrhage from the head of the pancreas, devascularization or massive disruption with involvement of the ampulla/proximal pancreatic duct and/or distal common bile duct. (See 'Duodenum and pancreas' below.)

Need for aortic occlusion — Any patient having undergone a resuscitative thoracotomy or balloon endovascular control of aortic blood flow should be immediately placed into a damage control algorithm because of the severe physiologic insult. (See "Endovascular methods for aortic control in trauma" and "Resuscitative thoracotomy in adults: Technique".)

Need for staged surgery — The need for a for second-look operation may be anticipated based on the injury mechanism. During surgery, the extent of injuries and the effects of large-volume resuscitation will become evident. The need for staged abdominal or thoracic wall reconstruction is suggested by:

●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

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 blood product-based and goal-directed resuscitation, the degree of interstitial edema from excessive crystalloid administration and total fluid overload have reduced. This has significantly lowered the incidence of abdominal compartment syndrome and the need to leave the abdomen open for this reason.

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) [5]. 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). Phase 0 also involves balanced component resuscitation centered on a 1:1:1 strategy of red blood cell:plasma:platelet transfusion. Increasingly, trauma centers are using whole blood in lieu of component therapy for initial resuscitation, when possible. (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. A balanced blood product resuscitation strategy is continued. (See 'Damage control laparotomy' below and 'Postoperative resuscitation' below.)

●Phase 2 – Resuscitation in the intensive care unit involves ongoing transfusion therapy centered mainly on plasma to establish euvolemia using a balanced approach and warming the patient. Frequently, viscoelastic testing is used to direct ongoing blood component-based resuscitation to address ongoing or lingering coagulopathy. These measures, along with appropriate airway and ventilatory management, will help to normalize tissue oxygen delivery and resolve acidosis and coagulopathy. (See 'Postoperative 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.)

Damage control surgery

Goals — The goals of damage control surgery are to first arrest hemorrhage and then to limit contamination, such as from gastrointestinal tract injury [6]. Implicit in this philosophy is the need to maintain blood flow to the vital organs, using temporary shunts if necessary. This holds true regardless of location.

To control hemorrhage, nonessential bleeding vessels are ligated, while essential bleeding vessels should be shunted or rapidly repaired. Identified injuries are temporized, and definitive repair is deferred until the patient has stabilized. Leakage from injuries to the gastrointestinal tract, tracheobronchial tree, or urogenital tract are controlled (eg, closure, exteriorization). (See 'Definitive repair' below.)

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, with a resultant increase in morbidity and mortality [7].

Temporary closure of the abdomen or chest promotes drainage of fluid and allows rapid return for surgical access if needed. Preemptive extremity fasciotomy prevents the negative sequelae of extremity compartment syndrome.

Effectiveness — Damage control surgery has not been validated prospectively. In observational studies, morbidity and mortality were reduced using a damage control approach compared with controls using a standard approach in which definitive repair of injuries was performed before abdominal closure [2,3,8-10]. Because of the large mortality benefit demonstrated, damage control was quickly adopted as the standard of care. While randomized trials would be desirable, any study withholding a damage control approach would be deemed unethical [11].

In the earliest report, the management of a cohort of 14 patients using standard hematologic replacement with completion of all facets of operation, and then closure of the peritoneal cavity, resulted in only one patient surviving (7 percent). Subsequently, 17 patients underwent damage control laparotomy, with 11 of 17 patients surviving (66 percent) [2]. A later retrospective study evaluated 46 patients with penetrating abdominal injuries who required laparotomy and had massive transfusion. While survival was similar overall (damage control: 55 percent; definitive laparotomy: 58 percent) among 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 (77 versus 11 percent) [3].

Order of conduct — Damage control methodologies can be instituted in the head, chest, abdomen, or extremities.

●(See 'Decompressive craniectomy' below.)

●(See 'Decompressive craniectomy' below.)

●(See 'Damage control laparotomy' below.)

●(See 'Damage control sternotomy/thoracotomy' below.)

●(See 'Pelvic/extremity stabilization' below.)

The order of conduct of damage control in multisystem trauma requires clinical judgement. Life-threatening injuries to the head, neck, chest, or abdomen take precedence over extremity injuries, which can be temporized with tourniquet control of bleeding or shunt placement. (See "Severe upper extremity injury in the adult patient" and "Severe lower extremity injury in the adult patient".)

When there is hemorrhage from both the chest cavity as well as the peritoneal cavity, classic teaching is to start with a laparotomy to obtain hemorrhage control in the abdomen, followed by intrathoracic hemorrhage control prior to control of contamination in the abdomen. However, if significant chest hemorrhage is evident (eg, large volumes from chest tubes, penetrating injury to the mediastinum), thoracic exploration should precede laparotomy. Nevertheless, the damage control principle of obtaining hemorrhage control prior to contamination control should be adhered to. If possible, simultaneous laparotomy and thoracotomy may be an option if there are sufficient operative personnel available. (See 'Damage control sternotomy/thoracotomy' below.)

PRESURGERY DAMAGE CONTROL — Damage control begins in the field and continues through transport and during the initial evaluation of the patient in the emergency department.

The need for a damage control approach can be readily recognized using physical examination based on clinical evaluation [12-14]. Recognition of severe physiologic abnormalities should prompt prehospital personnel to perform only those interventions that are absolutely necessary to promote gas exchange and control external hemorrhage [15-17]. As an example, orotracheal intubation should be avoided unless there is imminent risk to the airway as this intervention has been shown to increase mortality in under-resuscitated patients [18]. As such, intubation should be delayed until blood-based resuscitation has started in a severely injured patient who is in shock [18,19]. However, transfusion is increasingly being administered in the prehospital setting. One study reported a mortality benefit when the transport time exceeded 20 minutes for prehospital plasma transfusion compared with no transfusion [20].

Upon arrival to the emergency department, the nature and extent of injuries should be reassessed. Physical examination (vital signs, temperature), ultrasound, and laboratory studies (eg, base deficit, lactate, coagulation parameters) help assess the magnitude of the physiologic response to injuries and initial resuscitation efforts.

Implementation of phase 0 of damage control and communication from the presurgery team allows for faster administration of blood-based therapy to address hemorrhage and shock and allows the surgeon to better communicate phase 1 goals with the operative team (eg, anesthesia, nursing) or other specialists (eg, interventional radiology, orthopedic surgery, vascular surgery). (See 'Phases of care' above and 'Indications' above.)

Damage control resuscitation, which includes a balanced blood product resuscitation as noted above, should begin as early as possible. (See "Initial management of trauma in adults" and "Approach to shock in the adult trauma patient".)

DAMAGE CONTROL LAPAROTOMY — The fundamental strategy of damage control laparotomy, with the following priority, is to control abdominal hemorrhage, control gastrointestinal or urinary contamination, and provide temporary abdominal closure to prevent abdominal compartment syndrome and facilitate subsequent procedures once the patient has been resuscitated [21-23].

Damage control surgery is performed in a stepwise fashion.

Midline incision — 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 abdominal 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.

Pack and explore — 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. (See 'Control contamination' below.)

Control abdominal hemorrhage — In general, hemorrhage is controlled by resecting severely damaged nonessential organs (eg, spleen), leaving severely damaged essential organs packed (most commonly the liver), and ligating or shunting transected intra-abdominal vessels [24,25]. Intra-abdominal vessels that are not end vessels can be ligated (table 1). However, essential vessels should be shunted rather than repaired (picture 1) when rapid restoration of perfusion is needed so that other injuries can be addressed [24]. This approach maintains perfusion while also controlling hemorrhage.

Spleen — Splenic injury can usually be managed with rapid splenectomy for severe injuries (picture 2) or left upper quadrant packing for lesser degrees of injury.

Splenectomy is a life-saving procedure when bleeding from the spleen is the cause of hemodynamic instability. Splenectomy is also more appropriate for patients requiring urgent surgical management of other significant injuries that preclude taking the extra time needed for splenic salvage. In the setting of damage control, delayed splenic salvage can be considered (within 24 to 48 hours) for low-grade splenic injuries, provided that the bleeding is controlled with packing. (See "Management of splenic injury in the adult trauma patient" and "Surgical management of splenic injury in the adult trauma patient", section on 'Splenectomy versus salvage'.)

Liver — Bleeding from the liver is approached in a stepwise fashion, initially using simple measures, and progressing to more aggressive techniques as needed.

Initial control of bleeding is performed with manual compression (figure 2), portal clamping, or perihepatic packing. Ongoing mild-to-moderate bleeding from the parenchyma can be controlled using topical hemostatic agents, electrosurgical techniques, and ligation of the parenchymal vessels. For more severe injuries, suturing the liver or hepatic artery ligation may be needed. If these techniques fail, segmental liver resection may be needed. Postoperative angioembolization can also be considered. (See "Management of hepatic trauma in adults" and "Surgical techniques for managing hepatic injury".)

Evaluate the retroperitoneum — Exploration of the retroperitoneum is usually not necessary unless there is strong suggestion or concern for hemorrhage (eg, expanding hematoma in zone 1). A decision to explore the retroperitoneum is based on the overall condition of the patient; the injury mechanism, such as the likely path of the injuring projectile in penetrating trauma; the presence and size of hematoma; and the likelihood of ongoing hemorrhage. However, overly aggressive exploration of the retroperitoneum can turn a controlled situation into one of unmanageable hemorrhage. (See "Overview of the diagnosis and initial management of traumatic retroperitoneal injury", section on 'When to explore retroperitoneal hematoma'.)

Once major bleeding within the abdominal cavity under control, the bowel can be carefully retracted to allow a clearer view for the systematic evaluation the retroperitoneum while taking care to avoid worsening any contamination. The intraperitoneal organs make it impossible to see the retroperitoneum all at once. Thus, each area must be exposed in turn, as exposing one area will necessitate obscuring another from view. When retroperitoneal exploration is indicated, accessing the retroperitoneum involves systematic retraction of the abdominal contents, and frequently, their mobilization using left or right medial visceral rotation as indicated. The choice of direction depends on anatomic need for access. (See 'Aorta' below and 'Vena cava' below and 'Kidney' below.)

Aorta — It may be possible to treat aortic injuries with endovascular stenting, but exploration of the central retroperitoneal space (zone 1) may be necessary if there is an expanding hematoma or other reason to consider ongoing bleeding from the aorta. In this case, a right medial visceral rotation should be used to expose the infrarenal aorta, whereas a left medial visceral rotation maneuver is often necessary to obtain aortic control above the renal arteries. (See "Abdominal vascular injury", section on 'Abdominal aorta'.)

The aorta can be primarily repaired or shunted. Interposition grafting with autologous vein, biologic grafts, or synthetic grafts can be performed, but the time and physiologic deterioration for prolonged procedures should be considered. (See 'Evaluate the retroperitoneum' above and "Abdominal vascular injury", section on 'Abdominal aorta'.)

Vena cava — Most vena cava injuries can be treated nonoperatively because the vena cava is a low-pressure vessel and bleeding will stop due to tamponade against the retroperitoneum. However, expanding hematoma or evidence of ongoing hemorrhage from the vena cava requires exploration and direct repair, or in some cases, ligation. Exposure of the vena cava depends on the segment that is affected. (See "Traumatic and iatrogenic injury to the inferior vena cava", section on 'Approach to vena cava injury' and "Traumatic and iatrogenic injury to the inferior vena cava", section on 'IVC exposure by anatomic level'.)

Kidney — Most kidney injuries can be treated with angioembolization [26], but exploration and likely nephrectomy may be necessary in grade 5 kidney injuries with ongoing bleeding if a normal-feeling kidney is palpated on the contralateral side. The left kidney is accessed with a left medial visceral rotation and the right kidney exposed with a right medial visceral rotation. (See "Management of blunt and penetrating renal trauma", section on 'Renal exploration' and "Overview of traumatic and iatrogenic ureteral injury".)

In the rare event that both kidneys are injured, salvage should be attempted within reason. (See "Management of blunt and penetrating renal trauma", section on 'Surgical techniques'.)

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 [27,28]. 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) [29-32]. (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'.)

Stomach and intestine — When injury is identified or confirmed at abdominal exploration, a damage control approach can be accomplished by quickly securing the injured stomach or bowel to stop bleeding and/or gastrointestinal leakage. Definitive repair or resection can be delayed for up to 24 hours. The choice depends upon the clinical status of the patient, the severity of the specific injury, site of injury, and number and relationship of hollow viscus injuries to each other and the presence of other traumatic injuries. (See "Traumatic gastrointestinal injury in the adult patient".)

Duodenum and pancreas — The approach to duodenal or pancreatic injury depends on mechanism and grade of injury and whether the injury is isolated to the duodenum or pancreas or involves both. (See "Management of duodenal trauma in adults", section on 'Damage control' and "Management of pancreatic trauma in adults", section on 'Damage control'.)

●Damage control for isolated duodenal injuries may involve rapid closure of the injured segment or resection of a full-thickness duodenal injury without reestablishing continuity. (See "Management of duodenal trauma in adults", section on 'Repair of duodenal injury'.)

●Bleeding from the pancreas distal to the head of the pancreas can usually be controlled with packing and wide drainage, but if the injury is distal to the pancreatic neck, a distal pancreatectomy is advised. (See "Management of pancreatic trauma in adults", section on 'Operative management of pancreatic injury'.)

●Bleeding from high-grade pancreaticoduodenal injuries often cannot be controlled by packing, and thus resection without reconstruction may be needed. The pylorus, pancreatic neck, and proximal jejunum are stapled across and resected, then anatomic vascular control is obtained, and the common bile duct is ligated. The biliary tract can be drained using tube cholecystostomy or left to dilate to help with delayed reconstruction. Closed-suction drains are placed to control duodenal and pancreatic secretions. Following resuscitation and stabilization, definitive resection and reconstruction (Whipple) can be performed. (See "Management of pancreatic trauma in adults", section on 'Combined pancreaticoduodenal injuries'.)

Ureters, bladder — Intraperitoneal bladder injuries are sutured closed in two layers, while extraperitoneal injuries are initially managed with catheter drainage. (See "Traumatic and iatrogenic bladder injury".)

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 externalized as a conduit. Alternatively, the ureter can also be ligated with placement of a percutaneous nephrostomy, pending definitive repair. (See 'Evaluate the retroperitoneum' above and "Management of blunt and penetrating renal trauma", section on 'Renal exploration' and "Overview of traumatic and iatrogenic ureteral injury".)

When pelvic fractures 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.

Provide temporary abdominal closure — Temporary abdominal closure can be achieved in a variety of ways, which are discussed in detail separately. Negative pressure dressings (picture 3) 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 [33]. 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".)

OTHER DAMAGE CONTROL TECHNIQUES

Damage control sternotomy/thoracotomy — When physiology warrants a damage control approach, chest injuries can be managed, and although less commonly needed, damage control sternotomy/thoracotomy used, which refers 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. This will similarly allow for fluid drainage and a rapid second look if necessary.

The damage control approach to thoracic cardiovascular and pulmonary injuries is reviewed separately.

●(See "Resuscitative thoracotomy in adults: Technique", section on 'Control hemorrhage'.)

●(See "Overview of blunt and penetrating thoracic vascular injury in adults", section on 'Damage control surgery'.)

The need to keep the chest open is much less than that of abdominal injuries because the incidence of cardiac or mediastinal edema precluding the ability to close the sternum or other pathology resulting in the need to keep the pleural space open is much less common.

When necessary, a sternal wound is usually temporized by placing a large, inert temporary cover of the heart. Options include polyvinyl chloride (eg, large, sterilized intravenous bag) or other similar inert/nonadherent material. This temporary cover can be covered by standard gauze as needed. Drains should be placed in the mediastinum to allow for fluid efflux. (See "Surgical management of sternal wound complications", section on 'Management of the open sternum'.)

Damage control of the pleural space is easier technically, and many trauma surgeons use the same devices that are commercially available for the abdomen. Tube thoracostomy is not needed if the temporary coverage device is sufficiently permeable and can provide suction. (See "Management of the open abdomen in adults", section on 'Negative pressure wound systems'.)

Pelvic/extremity stabilization — Damage control of pelvic/extremity injuries often requires multidisciplinary cooperation. (See "Severe pelvic fracture in the adult trauma patient" and "Surgical management of severe lower extremity injury" and "Surgical management of severe upper extremity injury".)

Damage control orthopedic and vascular procedures can be used 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 surgery quickly places external fixation devices in patients who are too unstable to undergo definitive internal stabilization or those who have contaminated wounds [34,35]. These include pelvic or extremity splinting, traction, or external pelvic or extremity fixation (picture 4). Damage control 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 [36-38]. But in general, definitive repair is delayed until physiology has returned to normal, wounds associated with open fractures are clean, and subsequent procedures are less likely to become infected. (See 'Definitive repair' below.)

●(See "Surgical management of severe lower extremity injury", section on 'Primary fracture management'.)

●(See "Surgical management of severe upper extremity injury", section on 'Primary fracture management'.)

Damage control vascular surgery places temporary shunts into injured vessels to maintain blood flow (picture 5), rather than ligation or definitive revascularization, and liberally uses fasciotomy to prevent extremity compartment syndromes.

●(See "Surgical management of severe lower extremity injury", section on 'Damage control surgery'.)

●(See "Surgical management of severe upper extremity injury", section on 'Damage control surgery'.)

There is a low threshold to perform extremity fasciotomy following reperfusion of an ischemic limb. (See "Upper extremity fasciotomy techniques" and "Lower extremity fasciotomy techniques" and "Patient management following extremity fasciotomy".)

Decompressive craniectomy — Principles of damage control surgery can also be applied to neurosurgery. 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 the propensity for hypothermia to develop to allow for resuscitation and reconstitution of normal physiology in the intensive care unit setting [39].

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 [39]. 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 [40]. However, this study has been criticized regarding its inclusion criteria [41]. 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 [42,43].

POSTOPERATIVE RESUSCITATION — Resuscitation begins in the prehospital phase or emergency department phase of care and should be applied throughout all phases of damage control. Postoperatively, the goals of care in the intensive care unit are to continue resuscitation fluid (usually transfusion), 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. (See "Overview of inpatient management of the adult trauma patient", section on 'Consider other potential injuries' and "Ongoing assessment, monitoring, and resuscitation of the severely injured patient".)

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 packing placed for hemostasis.

●Segments of intestine that are in discontinuity are anastomosed 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 "Abdominal vascular injury" and "Surgical management of severe upper extremity injury" and "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 [44]. (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".)

●Both sternal as well as pleural space closure should be done with drains placed. Almost always, the drain should be placed on active suction. For the mediastinal space, options are chest tubes placed to a water seal, closed drainage system, or large-bore surgical drains that are placed on suction. For the pleural space, a standard chest tube arrangement is sufficient. (See "Surgical management of sternal wound complications" and "Post-traumatic rib cage and chest wall hernias".)

●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 – Severely injured patients often do not have the physiologic reserve to tolerate prolonged surgery that would be required for definitive repair of injuries. Damage control surgery treats only life-threatening injuries, purposefully delaying definitive operative repair until the patient's physiology has improved. Although the damage control approach began with the management of abdominal injuries, the basic principles have been extended and are standard of care for severe intrathoracic, vascular, orthopedic, and intracranial injuries as well. (See 'Principles of damage control' above.)

●Indications – Damage control should be used in severely injured patients with multisystem trauma based on the type of traumatic injury and the patient's physiologic response to the injury. There are no absolute, evidence-based models that predict who would benefit most from damage control. In general, damage control should be initiated for patients with massive transfusion, severe physiologic derangements (hypothermia, coagulopathy, metabolic acidosis), severe patterns of injury on imaging or identified in the operating room, and in those resuscitated with aortic occlusion or have need for staged surgery. (See 'Indications' above.)

●Phases of care – Damage control can be broken down into distinct phases of care including: presurgery rapid transport and triage, damage control surgery (stop bleeding, restore perfusion, limit contamination), perioperative resuscitation (balanced component transfusion), definitive repair of injuries temporized during damage control surgery, and delayed abdominal/chest/wound closure or coverage (figure 1). Damage control resuscitation is applied throughout all phases of damage control. (See 'Phases of care' above.)

●Damage control surgery – The goals of damage control surgery are to first arrest hemorrhage and then to limit contamination regardless of the site of injury (ie, intra-abdominal, intrathoracic, intracranial, extremity). Damage control surgery should be performed expeditiously to minimize additional physiologic insult. For patients with severe injury, using a damage control is approach is associated with reduced morbidity and mortality. The order of damage control (eg, abdomen versus chest) is based on severity of bleeding, although life-threatening injuries to the head/neck, chest, or abdomen take precedence over extremity injuries. (See 'Damage control surgery' above.)

Damage control surgery is performed in a systematic manner and described above.

•(See 'Damage control laparotomy' above.)

•(See 'Damage control sternotomy/thoracotomy' above.)

•(See 'Pelvic/extremity stabilization' above.)

•(See 'Decompressive craniectomy' above.)

●Resuscitation – 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 or by using whole blood), warming the patient, and providing appropriate airway and ventilatory management. 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 'Postoperative resuscitation' above.)

●Definitive repair – 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".)

●Delayed wound closure/coverage – 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.)