© Springer Nature Singapore Pte Ltd. 2017
Xiaobing Fu and Liangming Liu (eds.)Advanced Trauma and Surgery10.1007/978-981-10-2425-2_1Damage Control Theory in Treatment of Multiple Injuries
(1)
Department of Trauma Surgery, Tongji Hospital, Hua Zhong University of Science and Technology, Wuhan, People’s Republic of China
Abstract
Lethal triad of death is the most serious complication of multiple injuries, which often manifests as metabolic acidosis, hypothermia and coagulation disorder, and all lead to multiple organ dysfunction syndrome (MODS). During the treatment process, early effective control of all kinds of primary injuries and bleeding could maintain the stability of the internal environment for avoiding exhausting of patients’ physiological potential, then making it possible for patients to get definitive surgeries after resuscitation, which depends on the damage control theory (DCT).
Keywords
TraumaLethal triadMultiple injuryDamage controlAs modernization of nowadays society progresses, trauma has become the primary cause of death in patients under 40 years old, therefore a major public enemy of society. High energy severe multiple injuries can easily cause serious physiological disorders in patients, which often manifests as metabolic acidosis, hypothermia and coagulation disorder [1], known as the lethal triad of death, followed by secondary strike such as severe infection , systemic inflammatory response syndrome (SIRS) and sepsis , which can all lead to multiple organ dysfunction syndrome (MODS). During the treatment process, because of multiple injury sites and complex associated injuries, early stage inappropriate treatment and definitive surgery could result in aggravating the injury and patients often die of late stage exhaustion of physiological storage. Therefore, how to effectively control the primary injury in early stage of treatment and to actively prevent secondary injury have become an urgent problem for emergency and trauma surgeons. The main purpose of damage control treatment of multiple injuries is: early effective control of all kinds of primary injuries and bleeding, maintaining the stability of the internal environment, as well as avoiding exhausting of patients’ physiological potential, so that patients, especially those suffering from severe multiple injury, can get through the acute stress period safely and stably, making it possible for patients to get definitive surgeries after resuscitation. The time gap between the onset of the injury and the occurrence of lethal triad is critical to improve the success rate of severe multiple trauma treatment and improve the prognosis of patients. Therefore, this period is also defined as the new gold hour (NGH).
1 Damage Control Theory and Relative Concepts
Damage control theory (DCT) is the core of damage control . DCT is an emergency surgical staging principle, which emphasizes on temporary control of bleeding and further contamination instead of taking definitive surgery for anatomical repair, contemporaneously conducting resuscitation to ensure minimal tissue perfusion, avoiding excessive, low temperature, ineffective liquid infusion. DCT contains two primary concepts: damage control surgery (DCS) and damage control resuscitation (DCR) [2].
1.1 Damage Control Surgery
As a surgical strategy for periodic recovery of severe trauma patients, DCS aims to avoid the irreversible physiological damage caused by “lethal triad” [3]. Stone first raised the concept of DC on the Ann-Surg in 1983. In 1993 Rotondo established a standardized procedure regarding DCS, namely the three stage principle of DCS: early simplified surgery, resuscitation in ICU and late definitive surgery. The reasonable application of DC surgery can effectively reduce the mortality of patients with complicated trauma. DCS was first applied in abdominal trauma patients. In recent years, DCS has been gradually applied to the department of orthopedics, the department of Neurosurgery, the vascular surgery, especially the treatment of multiple injuries, and has made certain progress.
1.2 Damage Control Resuscitation
Derived from DCS, DCR was first pointed out by the American military trauma surgical consultant colonel HoLcomb in 2006 [4]. The basic principle of damage control resuscitation is to quickly identify patients with high risk of abnormal coagulation mechanism, and to reverse the abnormal coagulation, hyperthermia and metabolic acidosis by fluid resuscitation. It has provided people with insights into certain clinical medical problems. DCR is now becoming more and more important in the treatment of severe multiple trauma [5].
1.3 Secondary Strike
Patients with Severe multiple injuries often die from secondary strike such as MODS and MOF. This theory suggests that as a direct result of trauma, the first strike develops early. Secondary strike is a series of inflammatory reactions from SIRS, sepsis to MODS and MOF, resulting from inappropriate treatment and definitive surgery of the first strike. The purpose of DCT is to minimize the impact of secondary strike on patients.
1.4 New Golden Hour
With the systematic establishment of trauma organizations, development of trauma center, application of standard resuscitation method and improvement of modern blood bank technology, the ability to resuscitate trauma patients with extreme trauma has improved. The concept of “Gold hour” is understood to be the fastest speed and the effectiveness of resuscitation, and its ultimate goal is to reduce injury-to-incision time. This change does not simply indicate the transportation of the severe injured patients from the scene of the accident to the emergency room, rather than applying resuscitation in the operation room and eventually the ICU. The most appropriate meaning of “the new golden hour” is the critical time period before patients develop lethal triad in the operation room. ICU nurses must understand the importance of this triad, because it indicates the establishment of the concept of DC or DCS, as well as the medical team’s emphasis on damage control in trauma patients.
1.5 The Dual Meaning of DCT
The proposal and clinical practice of DCT has played an important role in the development of medicine [6, 7]. It is a milestone in the development of multiple injuries treatment. In recent years, DCT continues to improve and ripen. DCT consider surgeries to be a part of resuscitation, rather than an end in itself [8], and that the prognosis depends much on patients’ physiological limit, rather than surgeon’s efforts to restore anatomical structure. Therefore, there is a secondary meaning of DCT [9]: (1) to control, decelerate or prevent blood loss and infection caused by original trauma; (2) to reduce the damage brought by surgery and invasive procedure in order to stabilize patients, creating opportunities for following treatment.
2 Pathophysiological Basis of DCT
2.1 Metabolic Acidosis
When blood pH is below 7.25, the body is in a continuous hypoperfusion state. Normal pathway of glycometabolism changes, anaerobic glycolysis will replace aerobic metabolism under normal physiological state, resulting in the accumulation of lactic acid in the body. Therefore, the level of blood lactic acid can reflect the severity of acidosis in patients with multiple injuries. Previous studies show that there is a clear correlation between blood lactic acid level and mortality [10]. The survival rate is 100 % in patients who can clear lactic within 24 h, and the survival rate in patients who can clear lactic within 48 h is only 14 %. If the duration of surgery is too long, the patient will develop continuously and repeatedly low perfusion and hypoxia, resulting in excessive accumulation of lactic acid in the body, which leads to increased mortality.
2.2 Hypothermia
Blood loss, large number of cryogenic liquid perfusion and exposure of body cavity all lead to acceleration of heat loss. Thermogenesis dysfunction and loss of peripheral vasoconstriction during anesthesia can cause patients’ core temperature to drop under 35 °C. If the continuous hypothermia reaches patients’ body limit (below 32 °C for more than 90 min), the damage become irreversible [11], and death is inevitable.
2.3 Coagulation Disorder
Acidosis and hypothermia can cause reduction in thrombin, platelet count and synthesis of clotting factor V, VIII, as well as activation of fibrinolytic. Blood dilution caused by fluid resuscitation can further aggravate coagulation disorders, which can develop into uncontrollable DIC, seriously endangering patients’ lives. Therefore, patients can die of physiological exhaustion during or after invasive definitive surgery or procedures, which leads to application of DCT. Surgeons should not only tend to control the blood loss and infection, but also control damage caused by emergency surgeries and invasive procedures, keeping patients stable enough for follow-up treatment [12].
3 Indications of DCT
Grasping indications is very important in DCT application. Studies show that pH level, hypothermia and blood transfusion are sensitive index of patients’ prognosis, therefore important index of choosing DCS [13]: (1) patient status: severe multiple injuries, ISS ≥25, associated severe hemorrhagic shock , diastolic pressure <70 mmHg on admission, in need of emergency operation; (2) lethal factors: severe acidosis, hypothermia, non-mechanical coagulation disorder, pH <7.25, BE ≤−8 mmol/L, T <35 °C, PT >16 s, APTT >50 s or 50 % of normal value; (3) surgery: estimated resuscitation and operation time is more than 90 min, in need of large amount of blood transfusion (>10 u); (4) conflicts in treatment: hard to make priorities in case of severe and complicated injuries; (5) medical condition: in low level hospitals or when restricted by technical conditions, or dealing with large number of patients, definitive surgery can not be performed, precious time need to be saved for transportation. When meet the first requirement and any of the rest 4 requirements, DCS should be applied.
4 Three-Phases Principle of DCT
The physiological potential of severe multiple injury patients is often on the verge of exhaustion. Even if surgeons can perform complex surgery despite of technicality, patient would eventually die of exhaustion of physiological potential. Therefore, surgery ought to be considered part of the whole resuscitation progress. The outcome of treatment does not depend on surgically restoring anatomic relations, but on timely correction of severe internal environment disorder [14]. Inappropriate, unbearable operation will accelerate patients’ death. DCT reduces secondary strike to patients. Blood loss is reduced by methods of ligation and packing hemostasis. In the mean time reducing blood transfusion can lower the possibility for transmitted inflammatory factors and toxic substances [15]. Providing a better foundation for rapid resuscitation can significantly reduce patient mortality.
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