Damage Control Management: from the surgical concept to multidisciplinary care for selected patients

Jean-Paul Lechat Published in the journal : September 2019 Category : Anesthésie-Réanimation

Summary :

Initially considered specific for the severe polytraumatized patients, the concept of damage control (DC) has been extended to the acute medicine domain with a climax attained following recent attacks. As a result, this condition now mobilizes a series of actors from the chain of care.

In the pre-hospital setting, the DC with its requirement of early bleeding control consisting of setting a tourniquet and a pelvic belt has modified the ABC trilogy into C-ABC: "Control hemorrhages first", prior to "Airway - Breathing - Circulation". In the emergency setting, during the "golden hour", the team leader must assume four different tasks: supervise the lifesaving procedures, initiate the massive transfusion protocols, limit any additional workup to the essentials, and schedule the priority of the surgical action order.

In the operating room, the carrying out of interventions aimed at controlling bleeding and microbial contamination, along with tolerating unstandardized parameters except for temperature control upon admission, must be performed in the second hour, the speed of surgery being now the priority. In the ICU, homeostasis restoration within 36 hours should enable a secondary surgical procedure for anatomical and functional purposes to be conducted. At times, maybe even often, several intermediary interventions are necessary in order to perfectly control the hemorrhage and infection prior to undertaking the final surgery.

What is already known about the topic?

In the traumatology domain, the damage control surgery is primarily based on prompt and limited surgical interventions on an unstable polytraumatized patient. At the beginning of this new millennium, the terminology of "damage control resuscitation" has replaced it.

What does this article bring up for us?

The relevance of the hemostatic component under these conditions has been recently highlighted, due to a better understanding of the pathophysiology underlying trauma-induced coagulopathy.

The "Damage Control" concept, which is also applicable to obstetric and surgical hemorrhages, "second hit prevention", managing massive influx of wounded and humanitarian surgery patients, must concern all those involved in acute medicine, well beyond surgery.

In our specialized surgical reality without any "Trauma Surgeon", "leadership" proves to be essential for rapid management and efficient surgical synchronization. A better FAST control contributes to the respect of the delays of assumed responsibility.

Key Words

Damage control resuscitation, massive hemorrhage, trauma-associated coagulopathy, lethal triad