Abstract | The term Damage Control originates from the British Royal Navy, where it described intermediate emergency measures to bring damaged ships back into their harbor for definite repair. The term nowadays is analogously used in trauma care to describe an emergency treatment regimen for managing severely injured patients with life threatening hemorrhage. Damage Control comprises of Damage Control Resuscitation, which aims to initially stabilize the patient and Damage Control Surgery, which pursues to achieve rapid hemorrhage control in order to maintain the patient’s physiological functions, often at the cost of initial correct anatomical restoration.
Three main factors, that is to say coagulopathy, hypothermia, and acidosis, drive the physiological deterioration in trauma patients and are collectively referred to as the lethal triad. Beyond, there are several additional aggravating factors as for example shock and hemodilution. For a sufficient treatment all of them have to be addressed.
Permissive hypotension with blood pressure guided fluid resuscitation is a good way to initially combat hemodynamic instability. Additionally, the use of blood products is a pillar of DCR as it addresses coagulopathy and increases the tissue oxygen supply at the same time. Massive Transfusion Protocols facilitate blood product administration in trauma patients and provide pRBC, FFP and thrombocyte transfusion usually in the ratio 1:1:1. Blood pressure control can further be achieved by the use of vasopressors and coagulopathy of trauma is addressed by the early use of TXA, coagulation factor substitution and Ca2+ supplementation. Hypothermia is best approached by covering the patient adequately, warming infusions before administration, and the use of heating devices.
In the end, these measures serve to stabilize the patient, but chances for survival are slim without immediate surgical hemorrhage control. This starts at the site of injury by compression of the wound or the use of bandages and tourniquets. More advanced techniques include Balloon Catheter Tamponades and Temporary Intravascular Shunts. Especially in a combat situation, these measures can be performed even outside an operating room.
For most severe trauma cases, especially in abdominal trauma, Damage Control Surgery is performed before definite surgical treatment. It is important that DCR and DCS act together synchronously. The key to an unimpeded and sufficient management of a heavily injured patient is good communication amongst all members of the medical team at all times. |