Damage control in the critically ill and injured patient

Ideally, the trauma celiotomy should be considered in three phases, which m ay or may not be separated temporally. They are: a) damage control; b) rest itution of physiologic reserve; and c) reconstruction. Perhaps the most imp ortant and effective aspect of damage control is to decide to pursue this a lternative early. The surgeon may often be able to predict those patients w ho are at such high risk that damage control should be considered in the pr eoperative planning. Patients who can be included in this category are: pat ients with profound shock, hypothermia, and acidosis preoperatively; coagul opathic patients; patients with severe debilitating problems such as cirrho sis, chronic obstructive pulmonary disease (COPD), and severe atherosclerot ic vascular disease. Consideration should be given to making an expeditious trip to the operating room with damage control celiotomy followed by resus citation in the ICU. It is more important to fight a holding maneuver in th e initial battle so that the patient will stay alive long enough for the su rgeon to help save his or her life and win the war. The goals of damage control are to: a) identify injuries; b) control hemorr hage; and c) control contamination. Initial attention should be directed to suturing of vascular injuries, decreasing the level of contamination from bowel injuries, and packing of solid organ injuries. Efforts should not be made to restore bowel continuity or perform definitive procedures if the pa tient is in severe physiologic distress. Guidelines for use of the damage control approach include any trauma patien t requiring a celiotomy who meets ally of the following criteria: a) develo ping a base deficit worse than -15 mmol/L in a patient <55 yrs or worse tha n -8 mmol/L in a patient >55 yrs or ill any patient with a head injury; b) lactate of >5 mmol/L; c) temperature of <35 degrees C; d) a prothrombin tim e of >16 sees; e) partial thromboplastin time of >50 sees; f) transfusion o f greater than or equal to 10 units of blood over 4 hrs; g) a pH of <7.18; h) oxygen consumption index of <110 mL/min/m(2); or i) need for a prolonged operation.