Damage Control Philosophy in Polytrauma

Abstract

Severe traumatic injury i. a public health care problem; with injuries accounting for 12 % of the global mortality. Continued improvement in the .urvival of severely injured trauma patients i. a paramount goal. Bailout/damage control .urgery following trauma has developed as a major advance in .urgical practice in the last twenty years. The principle. of damage control .urgery defied the traditional .urgieal teaching of definitive operative intervention and were .Iow to be adopted. Currently, damage control surgery has been .u ..... fully utilized to manage traumatic thoracic, abdominal, extremity, and peripheral vascular injuries. In addition, damage control surgery has been extrapolated for u.e in general, vascular, cardiac, urologic, and orthopaedic .urgery. Stone et aI were the first to describe the "bailout" approach of .taged .urgical procedures for severely injured patients. Thi. approach emerged after their ob.ervation that early death following trauma was associated with .evere metabolic and phy.iologic derangements following severe ex.anguinating injurie •• Profound .hock along with major blood 10 •• initiate. the cycle of hypothermia, acidosis, and coaguIopathy. During the 1980., hypothermia, acidosis, and coagulopathy were described as the "trauma triangle of death" which makes the prolonged and definitive operative management of trauma patients dangerous. The management technique, now described as "damage control" by Rotondo et aI, involves a multipha.e approach, in which reoperation occurs after correction of physiologic abnormalities.

Damage control orthopedics applied in an 8-year-old child with life-threatening multiple injuries

“…[2,3,5] In adults, the lethal triad includes a preoperative core body temperature of <34°C, arterial pH <7.2, INR/PT >1.5 times normal, clinically observed coagulopathy, and blood loss of more than half the patient's blood volume. [1,4]…”

“…Although the child described in this report showed signs of beginning hypothermia with a body core temperature of 36.2°C, mild acidosis with a pH of 7.31, base excess of −6.3, and prolonged INR, these parameters did not meet the criteria of the lethal triad. [1,4] However, due to the high impact of the trauma and the multiple fractures and soft tissue injuries, we decided to apply the principles of damage control orthopedics. The pathophysiological background of damage control surgery is based on the systemic impact of polytrauma and the additional trauma caused by the operative intervention.…”

“…[2,3] However, pediatric and orthopedic surgeons should be aware of the principles of damage control surgery and utilize it when necessary. Surgeons must recognize the so-called “triangle of death.” [4] It is a vicious cycle of acidosis, hypothermia, and coagulopathy that interrelate, eventually become irreversible, and lead to death. [5]…”

Immediate Postoperative Coagulopathy Predicts the Long-term Survival of Traumatic Brain Injury Patients: a Retrospective Cohort Study

“…The main causes of early death in trauma victims are acidosis, hypothermia and coagulopathy, which are related to and in uence each other. Thus, this vicious circle is often referred to as the " trauma triangle of death " [3,4]. Trauma-induced coagulopathy manifests as a state of hypercoagulopathy trending towards thrombosis [5] and a state of hypocoagulopathy with progressive intracranial hemorrhage and increased systemic bleeding [6,7].…”

Coagulopathy on the first postoperative day predicting the long-term survival of traumatic brain injury patients

“…The main causes of early death in trauma victims are acidosis, hypothermia and coagulopathy, which are related to each other and influence each other. Thus, this vicious circle is often referred to as the " trauma triangle of death " [3,4]. Trauma-induced coagulopathy manifests as a state of hypercoagulopathy trending towards thrombosis [5] and a state of hypocoagulopathy with progressive intracranial hemorrhage and increased systemic bleeding [6,7].…”